Digital First Primary Care for those with multiple long-term conditions: a rapid review of the views of stakeholders

Article history

The research reported in this issue of the journal was funded by the HSDR programme or one of its preceding programmes as award number 16/138/31. The contractual start date was in January 2021. The draft manuscript began editorial review in December 2022 and was accepted for publication in July 2023. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HSDR editors and production house have tried to ensure the accuracy of the authors’ manuscript and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this article.

Copyright statement

Copyright © 2024 Newbould et al. This work was produced by Newbould et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited.

2024 Newbould et al.

What is Digital First Primary Care?

This rapid evaluation has conceptualised Digital First Primary Care as described below:

Digital First Primary Care is when a patient’s first contact with primary care is through a digital route, either through a laptop or smartphone. The patient enters details of the issue which they wish to consult a health professional about, either by completing a form or by entering a free-text narrative. The patient will then be contacted by the practice, usually on the same day, about their issue.

Practices which use this approach also provide a mechanism for access for those unable to use the digital route. Patients telephone the practice and a member of practice staff enters the information into the digital interface and the request is dealt with by the practice in the same way as it would be if the patient entered the information digitally.

Most practices enable patients to order repeat medication online; we would not define this as Digital First Primary Care, as the purpose of contact is not to see or speak to a health professional, rather to obtain medication.

The term, Digital First Primary Care, originated from an NHS programme during the COVID-19 pandemic where it was defined as follows:1

Digital First Primary Care is the name of a programme which supports the transformation of primary care by promoting the implementation, understanding and improvement of digital tools within general practice. 1

Figure 1, produced by NHS England, outlines the various patient pathways, from when a patient first contacts their practice digitally to the holding of a consultation. 1

FIGURE 1.

Digital First Primary Care pathways, taken from Bakhai et al., NHS England. 2

Most general practices offer Digital First Primary Care by purchasing the approach from a commercial provider, although practices may also create the approach themselves. The design of Digital First Primary Care platforms varies by commercial provider, although the main principles are the same. The patient inputs their symptoms and concerns through a digital platform, such as a computer or smartphone, either via a set of questions within a digital algorithm or through a free-text submission. Once the information is entered, the patient is then given an appropriate response, which could be from a staff member within the practice or automatically generated by the algorithm for example an online message. This response could, for example, offer guidance for self-care, advice to attend an accident and emergency service (if the problem is deemed to be a serious one that cannot wait), a message back from a professional or a suggested telephone, video or face-to-face appointment with a general practitioner (GP) or other member of the practice team. Most models enable swift responses from practices back to patients, usually on the same day, and if a consultation is required, this is usually on the same day too. These approaches have been advocated by NHS England to enable clinicians to prioritise the care of patients in the most need. 2

Digital First Primary Care can, therefore, lead to a conventional general practice consultation style, such as a telephone consultation or face-to-face consultation, or a less traditional consultation, such as the health professional messaging the patient. Yet, the consultation is framed by the information the health professional receives ahead of the consultation, submitted through the digital route. Digital First Primary Care approaches may also enable practices to more easily provide video consultations.

Table 1 outlines the principles of the Digital First Primary Care consultation as compared to a traditional general practice system.

Accessing services via a digital route may mean that a patient’s experience of care differs from that of a patient accessing the practice via an alternative route, such as by telephone or by visiting a surgery. For example, messages about a person’s care might be exchanged between the patient and professional or the clinician may conduct the consultation having prior written information from the patient, for example discussing a patient’s diabetes having already received their blood-sugar readings via message, which would not be possible if the patient had not accessed care digitally.

The exact nature of the Digital Frist Primary Care patient pathway depends upon the provider used, but most use either a free-text approach or an algorithm approach, Figures 2 and 3 illustrate examples of patient pathways from initial contact with the practice to the outcome, using two different approaches to Digital First Primary Care.

FIGURE 2.

Example of a Digital First Primary Care patient pathway: free-text approach.

FIGURE 3.

Example of a Digital First Primary Care patient pathway: algorithmic approach.

A ‘free-text approach’ (see Figure 2) is where a patient enters the nature of their problem in the system in their own words. The patient then receives an automated response to say they will hear back from the surgery. The response is then reviewed by a healthcare professional and the response is either dealt with by the administrative team at the surgery, for example a sick note, or a response is provided by a health professional in the form of a message or consultation, by a variety of means.

An alternative approach is an algorithm approach (see Figure 3) where the patient completes an online form which asks a series of questions. The form gives the patient options to choose from, for example the part of the body that the problem is in, the duration of time they have had it. After the query has been submitted a response is automatically generated and immediately sent to the patient. This could include self-help, if the problem is deemed as not requiring a primary care health professional, or to contact a pharmacist. If the problem is considered urgent, a message is sent telling the patient to dial 999 or attend an accident and emergency department immediately. Alternatively, patients are sent a message to say a health professional from the practice will contact them.

It should be noted that the figures outline examples of ‘typical’ patient pathways for patients using these Digital First Primary Care approaches; however, the ways in which the systems have been implemented and are used in practice may vary across general practices. For example, they may have different staff responsible for dealing with requests within a practice or some practices may use messaging or photos more than others.

English policy context

Scoping for this project began in July 2019, at a time when general practices throughout England were struggling with rising demand from patients with complex health needs, more work being transferred from secondary to primary care and increasing difficulty in recruiting and retaining GPs. 3,4 The General Practice Forward View (2016) aimed to help GP practices reduce and better manage their workload and the increased use of digital technologies was advocated. 4 The digital ambition for primary care was further endorsed in the NHS Long Term Plan (2019), which set out a target that, within the next 10 years, the NHS would offer a ‘Digital First’ option in primary care for most patients,5 with the aim that this would enable ‘longer and richer face-to-face consultations with clinicians where patients want or need it’. 5 More specifically, the plan set out a milestone that every patient in England would be able to access a Digital First Primary Care offer by 2023/24. 5 The 5-year framework for GP contract reform also reflected this policy shift towards digital approaches, including a requirement that practices should ensure that all patients have the right to Digital First Primary Care, including online consultations, by April 2020 and consultations via video by April 2021, with the aim to provide this access as quickly as possible. 6

Despite the increasing policy shift towards digital approaches, most GP surgeries were not operating in this way in early 2020, with an analysis of primary care data suggesting that 13–15% of consultations were conducted remotely in January 2020. 7 Wider studies suggest that factors such as a lack of training, inadequate technology and concerns about issues such as inequity of access, safety and workload limited the use of alternative approaches to face-to-face consultations, as well as low patient uptake in practices where digital approaches had been adopted. 8–10

The impact of COVID-19 on Digital First Primary Care

The COVID-19 pandemic saw a rapid change in modes of service delivery in general practice, with all GP surgeries having to rapidly adapt their services to provide non-face-to-face consultations, which could be supported by digital platforms. At the time of scoping for this project in 2019, the uptake of digital primary care was modest across England. In response to the COVID-19 outbreak, general practices had to quickly adapt their ways of working to reduce footfall in GP surgeries, protecting patients and staff from infection. 11

It was noted by providers that there was a dramatic increase in the adoption of Digital First approaches in primary care in response to COVID-19, although there are no publicly available data. Data are available, however, on the use of other forms of consultation. An analysis by The Health Foundation suggested that remote consultations increased from < 20% to > 50–60% of all consultations at the peak of the first national lockdown. 7 This trend appears to have continued, with further analysis conducted by the Health Foundation demonstrating that March 2021 saw the highest number of telephone appointments ever, at 11.4 million compared to 3.5 million in March 2019. 12 More recently, in 2022, the British Medical Association (BMA)13 reported that the ratio of face-to-face versus remote appointments has changed alongside the waves of COVID-19. In 2022, under one-third of consultations were remote, with September having the highest number of face-to-face appointments since before the pandemic. 14

When looking at specific types of digital approaches, evidence from the Health Foundation examining data from practices using one specific provider, suggested that patient preference for consultation via SMS/online messaging increased from 26% of requests before the pandemic to over a third in 2020 and 2021 and that a telephone consultation was the most popular patient preference. 15 While the majority of requests were initiated online (rather than by telephone or in person) before the pandemic, this continued to rise from 60% in June 2019 to 71.8% during 2021. 15 In addition, between March and June 2020, the use of video by patients to communicate with GP surgeries increased 50-fold compared to before the pandemic,11 although, compared to other forms of digital communication, the use of video was low and this remains the case more widely, accounting for around only 0.6% of consultations at the time of writing. 14

Context within English general practice at the present time

The changes described have taken place amidst an extremely challenging climate for general practice in England, with workforce shortages and increasing workload which were apparent even before the pandemic. The number of full-time equivalent, fully qualified GPs has fallen since 2015 yet GP appointment numbers are higher than they were before COVID-19,29 and the average number of patients GPs are responsible for has risen. 13 A provider poll carried out in August 2022 showed that 90% of the primary care providers who responded agreed or completely agreed that they were finding it difficult to recruit staff. 30 Yet the number of healthcare professionals in total (excluding GPs) has increased by over 6000 during the last year, in line with the government’s target to increase the number of health professionals working in general practice. 5,31 This could be linked, in part, to the Additional Roles Reimbursement Scheme, introduced in 2019 as part of the GP contract framework, to support the recruitment of 26,000 additional staff working in general practice by 2023/24 and aid an increase in the number of annual appointments in general practice. 32,33

Relatedly, the latest GP work–life survey highlighted that a third of GPs plan to leave direct patient care within 5 years, with GPs reporting the greatest stress from a range of factors including increasing workloads, long working hours and increasing patient demands. 34 Further, as a result of the pandemic, primary care professionals have been working in an uncertain and ever-shifting environment,35 and the impacts of COVID-19 on primary care were considerable,12 with the whole system now seeking to recover.

More widely, these pressures have been accompanied by negative media coverage and a narrative that general practice is ‘closed’, and less willing to see patients face-to-face. A statement from the chair of the BMA’s GP committee discussed ‘anti-GP’ rhetoric in the media following a media campaign about GP face-to-face appointments in England. 36 This was supported by a recent study, which found that newspaper coverage of remote consulting was highly negative, that remote consultations had become associated with poor practice and that some papers were ‘leading the war’ on general practice. 37

Aims of this study

This rapid evaluation originally had one distinct aim: to understand the experiences of those with multiple long-term conditions of Digital First Primary Care, from the perspectives of patients, their carers and healthcare professionals. However, due to recruitment challenges and a lack of uptake to the study from general practice, largely due to COVID-19 pressures, the focus instead was amended to the experiences of healthcare professionals and stakeholders. As a result, minor amendments were made to the research questions.

As a result of the scoping work, where relevant literature on the use of Digital First Primary Care by patients with multiple long-term conditions was engaged with and a workshop with patients [members of the BRACE patient and public involvement (PPI) group] was held, four research questions were identified by which to address this aim. 1

• What is the experience of Digital First Primary Care for health professionals and stakeholders (including academics, policy makers and Digital First Primary Care providers), both before and during the COVID-19 pandemic?

• What is the impact of Digital First Primary Care on the nature of consultations, from the perspective of health professionals and stakeholders, for patients with multiple long-term conditions and their carers? This includes aspects of communication, timeliness of care and continuity of care.

• What, if any, are the advantages or disadvantages of Digital First Primary Care for health professionals when providing care for patients with multiple long-term conditions?

• What lessons can be learnt from staff and stakeholders 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?

While in Chapter 1 we have set out a definition of Digital First Primary Care, it should be noted that, within the literature and during interviews with health professionals and stakeholders, firm distinctions and definitions were often not used.

Impact of Digital First Primary Care on patients

Digital First Primary care could impact patients in a range of ways, as identified by multiple studies on this topic. Here, we discuss the impacts on patients in general and later in this section we discuss its use and impacts specifically for patients with multiple long-term conditions.

Some studies found that patient satisfaction could be high with regards to digital methods of engaging with GP practices; patients valued having multiple routes to communicate with their practice and appreciated the convenience of digital engagement (e.g. no need to travel and ability to minimise the amount of work missed). 38–43 However, other studies found more mixed evidence in relation to patient satisfaction, which could be due to differences in the digital literacy of patients and the complexity of the patient’s issue (see later). 43–45 The method of data collection for studies which explored this issue can also be a challenge (e.g. collecting data online only may skew data collection towards the views of the digitally literate, who may have more favourable views). 40

There was mixed evidence on how comfortable and confident patients felt discussing their symptoms remotely. One study found that patients had concerns around whether they could communicate their symptoms effectively remotely,40 but another found that patients may feel more confident doing this remotely. 44

There were some challenges identified in the literature for patients using digital methods of engagement with their practice. These included concerns over privacy/confidentiality, language barriers, a less holistic assessment of the patient, a heightening of inequalities, less continuity of care and the reduced quality of patient–clinician interactions. 43,44 There could also be issues with staff phoning patients at different times than they had originally specified. 42,44 One study found that one of the key issues raised by patients was the importance of respecting their time and understanding how appointments fit in with their lives. 42

Impact on primary care staff

Primary care practice staff are also impacted by the introduction of Digital First Primary Care approaches and have opinions about its use. Here, we describe some of the benefits and challenges healthcare professionals may face when supporting patients both with and without long-term conditions.

Some studies found staff to be positive about the introduction of a new digital system, feeling confident in patients using it and that it could complement existing services. 38,39,41 As with patient impact, there is also the benefit of reduced transmission of infectious diseases, such as COVID-19, due to less footfall in the practice. 44 Some of the benefits of remote consulting were found to be prioritising patients with poorly controlled conditions, greater control over the working day for GPs and patients being more direct in describing their issue and raising fewer problems during phone consultations. 48 Video consultations were thought to be particularly useful for dynamic patient assessments, assessing children, training patients/carers in at-home procedures (e.g. wound care) and connecting with elderly/vulnerable patients. Using text messaging was thought to be effective for fitness to work notes, prescription information and risk assessment questionnaires for patients with long-term conditions. 48

There are also some important concerns from the perspective of staff, such as uncertainties about integrating new digital systems with existing processes and greater difficulties in healthcare professionals making clinical decisions when consulting remotely. 39,44 A challenge of the new ways of triaging patients included reaching out to vulnerable patients, for example those without a carer or homeless patients. 49

Studies have found mixed evidence on whether staff workload changes as a result of introducing digital systems,44,45 although many do note an increased staff burden and unintended consequences on workload in primary care or elsewhere. For example, one study found that most e-consultations resulted in phone or face-to-face appointments, which GPs felt duplicated their workload. 8 A 2019 rapid evidence review found that, while there was some evidence that Digital First services could reduce the burden on primary care, this differed across studies, depending on the outcomes of interest and the type of digital approach used. 50 In a 2021 mixed-methods study which explored GPs’ experience of triaging patients during the pandemic, GPs reported that telephone triage took longer than expected and felt similar to conducting a remote consultation, and this may result in confusion for the patient as to the purpose of the triage call. There may also be a risk of over-referring for face-to-face appointments (rather than remote) due to concerns over missing something a patient may be presenting with. 49 The Nuffield Trust published a report in 2022 on the practical challenges related to remote consultations and identified that remote consultations took longer than face-to-face consultations and there were greater referrals to other services. 38

There are also some concerns over patient safety. For example, studies identified challenges in picking up non-verbal cues from patients when conducting remote consultations, difficulties in building trust and rapport during shorter remote consultations, feelings of fatigue due to dealing with higher clinical risk, potential problems with missed or delayed diagnoses and safeguarding issues. 38,48,49 A longitudinal exploration of remote consulting during the pandemic found that telephone consultations required additional (and careful) questioning as complex cases which previously would have been seen in person were being managed by phone. 48

Summary

In summary, while Digital First Primary Care has been subject to previous research, this has often not included a specific focus on patients with long-term conditions. In particular, there is a significant gap in understanding its use and impact for patients with multiple conditions and the views of carers. For those studies that do include patients with multiple long-term conditions, this is often a secondary consideration rather than the core focus of the study (as outlined in this chapter). In addition, most studies focused on experiences of remote consultations as opposed to exploring the entire Digital First Primary Care pathway, starting from the initial (digital) contact with a GP practice. Therefore, our study is well placed to fill this gap in understanding and evidence from the perspective of healthcare professionals and stakeholders on the use of Digital First Primary Care specifically for patients with multiple long-term conditions.

General approach

Sampling and recruitment of general practices delivering Digital First Primary Care

Two commercial providers of Digital First Primary Care (Provider A and Provider B) agreed to participate in our study and assist with the identification of practices using their approach. At the time of writing this report, we were unable to locate publicly available information to determine how many commercial providers were providing Digital First Primary Care services in England and how many practices and GPs were using these services.

Providers varied in the approach they were happy to take in terms of recruitment, so it was necessary for the research team to be flexible. One provider (Provider A) supplied the study team with a list of practices operating a Digital First approach for 6 months or more for the research team to contact directly. Provider B preferred a different approach, by which they sent recruitment material to a randomly selected sample of 150 practices using their Digital First approach on behalf of the research team. Due to recruitment challenges, the research team also contacted a super-partnership which shared recruitment material across their 45 practices. Practices across the super-partnership used both Provider A and B’s Digital First Primary Care platforms.

Our initial approach was to use a maximum variation sampling strategy to identify general practices, 54 for example with varied list sizes, locations (urban or rural) and including areas of high deprivation and with ethnic diversity. However, due to the recruitment challenges outlined, it was necessary to adopt a convenience sampling strategy.

Two study team members (MS and LH) approached all 179 practices from the list provided by Provider A as well as interested practices from the super-partnership via (1) an electronic invitation via e-mail sent to practice managers (or central practice e-mail addresses if the practice manager e-mail was unavailable) explaining the purpose of the study and their potential involvement, followed up by (2) weekly telephone calls to arrange meetings with primary care staff to discuss the study, concluding with (3) a final e-mail reminder for practices who had not responded within the 6–8 week timeframe. Despite approaching 179 practices for Provider A, only 2 were recruited.

For Provider B, an e-mail invitation was drafted by the research team and sent to a sample of randomly selected practices by the provider. Practices interested in taking part in the study were asked to get in contact with a member of the research team to arrange interviews. Initially, 50 invitations were sent out, followed by another 100. However, no practices were recruited via this method. Due to these recruitment challenges, the research team approached a GP super-partnership, whereby an e-mail invitation was sent out to the 45 practices in the partnership on behalf of the research team. This approach was successful and resulted in five practices being recruited to the study. In addition, members of the research team approached practices they had recruited to other research studies to see if they would like to take part in the study. This resulted in one further practice being recruited to the study. This meant a total of eight practices were recruited. All practices within our sample were using Digital First Primary Care in some capacity prior to the COVID-19 pandemic. A summary of the practice recruitment is provided in Table 3. Due to the challenges with recruitment, it took place over an 8-month period (January to August 2022) to ensure that we recruited enough practices to collect sufficient data.

Sampling and recruitment of patients and carers

To identify patients with multiple long-term conditions, practice staff (and central administrators as part of the super-partnership) were asked to run a search of patient records to identify suitable patients. The research team worked with practices to refine their search depending on the clinical system used. The following inclusion criteria were used:

• Aged 18 years and over.

• Living with at least two long-term health conditions (in accordance with NICE guidance).

• Have accessed Digital First Primary Care services recently.

The practices were asked to send invitations to up to 100 patients at a time who met the above search criteria in order to recruit up to four patients per practice. The intention was for practices to send a study invitation on behalf of the research team and the patients/carers to return a form to the research team if they wanted to participate in an interview. However, due to capacity challenges in the recruited practices, seven of the practices were unable to develop and run a patient search on their database. In the eighth practice the patient search was conducted but GP staff were not available to review the list of patients, a requirement of the study, within the timeframe of the project.

Other approaches to recruit patients and carers to this project, outside of general practice, were considered by the BRACE team in consultation with the steering group and PPI group. However, due to COVID-19 and pressures within other organisations, and the time constraints of the project, this was not possible.

Recruitment of health professionals and expert stakeholders

The study team invited any primary care clinician and allied health professional who was involved in using the Digital First Primary Care approach when managing patients living with multiple long-term conditions for an interview. A senior clinician or practice manager was identified across each practice to act as a gatekeeper to identify relevant staff to take part in interviews. A gatekeeper was defined as a person who could act as an intermediary between a researcher and potential participants with the authority to deny or grant permission for access to potential research participants. 55,56 The gatekeeper facilitated the identification of key individuals involved in the design, implementation, governance or use of Digital First Primary Care platforms for patients with multiple long-term conditions.

Staff were provided with a participant information sheet (see project documents) and completed interviews online (MS Teams/Zoom). Each respondent was provided with the participant information sheet in advance (see project documents). Interviewees had the opportunity to ask questions about the study and signed a consent form (see project documents) prior to participating in the interview, including whether they consented to the recording of the interview. Participants were informed that they were entitled to withdraw from the study at any time and were given information about how to find out more about the study and how to raise any concerns about its conduct.

The evaluation team originally planned to complete 2–4 interviews across each practice (1–2 GPs and 1–2 other health professionals, 12–24 interviews total). However, due to the previously mentioned recruitment and capacity challenges within primary care, 14 interviews were conducted with staff. These were held with 10 GPs and 4 nurses. The interviews lasted between 20 and 60 minutes.

Expert stakeholders were defined as participants that had regional or national level expertise in Digital First Primary Care, including those who may have critical oversight at a level beyond individual practices, for example GP federations and CCGs, decision-makers at a national level, those who work in academia, policy think tanks or commercial companies. The sampling was purposive, identifying participants with topic knowledge of Digital First Primary Care from the groups outlined. Potential participants were identified from the scoping of the published literature, grey literature, policy documents and organisations identified during the scoping work. Snowball sampling was also used – at the end of each interview, participants were asked ‘is there anyone else with topic knowledge in this area that you think we should speak to?’. E-mail invitations to participate in an interview, with information sheets, were sent to 30 contacts, 14 interviews were conducted with 15 participants. No explicit declines were received. The interviews lasted 30–75 minutes.

Fieldwork was completed in parallel across general practices and expert stakeholders (March to September 2022) by three members of the research team with experience of undertaking interviews and qualitative data analysis (lead by JN with MS and LH). JN, MS and LH were responsible for all communication and data collection; a small number of recordings of interviews completed by LH and MS with primary care staff for were reviewed by JN.

A topic guide for use with NHS staff was developed, adapted (as a result of changes to theresearch questions) and used by researchers as an aide-memoire during the interviews (see Appendix 1). The main themes covered by the topic guide were: reasons for implementing and using a digital platform; staff training (if any); the benefits and drawbacks of Digital First Primary Care; the impact on managing patients living with multiple long-term conditions; the impact on practice workload and staff satisfaction levels. A topic guide for stakeholders was developed covering similar topics with specific questions on their perceptions about the benefits and drawbacks of Digital First Primary Care for patients and submitted as an amendment for ethical approval.

The interviews were audio-recorded (subject to consent being given), transcribed verbatim by a professional transcription service, anonymised and kept on the University of Birmingham’s research data server in compliance with the General Data Protection Regulation 2018 and the Data Protection Act 2018.

The study did not formally aim to achieve data saturation, but participant samples were regularly reviewed during the data collection phase, while a purposive approach was taken to target specific stakeholders that were under-represented (i.e. nurses).

Analysis and interpretation

Wider context in which Digital First Primary Care is being implemented

As described in Chapters 1 and 3, the fieldwork for the evaluation was undertaken during an extremely challenging period for general practice. Here, we will briefly discuss the points raised by the interviewees related to the wider context in which Digital First Primary Care was being implemented. While this is not exclusively relevant to patients with multiple long-term conditions, these contextual challenges will particularly impact patients who see a GP more frequently, which includes those with multiple long-term conditions.

Workforce recruitment and retention challenges within primary care were frequently mentioned by participants. Staff shortages and difficulties filling vacancies were a key issue across general practice in relation to both clinical and non-clinical staff, with shortages of working GPs highlighted as a particular issue. The interviewees reflected on how the number of GPs was falling, with fewer entering primary care and some retiring or leaving for other reasons. This challenge aligns with national data from the BMA, who note that the number of GPs in England has grown very little since 2015. 13 Linked to this, a reliance on locums in the absence of being able to recruit permanent staff to practices was reported by participants.

So if you go pre-COVID, there were a range of things that were making life more difficult for GPs. The population was getting older. The population was increasing. The number of GPs was decreasing.

Interview 7, researcher

For those working in general practice, challenges were reported with staff working in busy and pressured environments, putting a strain on the workforce and causing staff burnout. This burnout of healthcare professionals following the COVID-19 pandemic has also been reported more widely.

… I have worked in the NHS my whole career and I have never worked so hard. Yesterday I got in at half past six, I did prescriptions while eating my sandwich over lunch because we had so many of them, and I got out of the building at half seven last night and I categorically did not stop from the moment I got in the door to the moment I left – and that’s really a new way of working – the pressure is intense. I mean, I think that’s probably the defining feature at the moment and the thing that’s going to decide what happens next, is the fact that there’s intense pressure, breaking pressure at the moment in the service … I can’t get patients seen.

Interview 2, GP

In terms of the wider healthcare system, pressures in secondary care, particularly following the pandemic, were also having an impact on primary care and increasing the demands on services. Some participants reflected on how an increasing amount of work was coming out of hospitals and into primary care, with GPs having to take on work that they may not feel qualified to do and manage patients they felt should be cared for in secondary care. This challenge of the pressure of secondary care impacting primary care has also been identified in other studies (e.g. Baird et al. 201859).

… There’s huge frustration with waiting times and secondary care, with additional workload being placed on primary care because of waiting times in secondary care, and having to manage patients who really need to be managed in secondary care, but because they can’t get an appointment yet or they have months to wait.

Interview 9, Digital First Primary Care company stakeholder and GP

For many participants, managing increasing patient demand was a challenge. While participants reported that demand had subsided during the pandemic as patients contacted health services less frequently (despite some needing care), demand was now felt to be rapidly increasing to levels which were unsustainable. High demand is a challenge identified from national data analysis by the BMA, for example, appointments in the winter of 2021 (very shortly before recruitment for this study started) reached ‘record highs’. 13

It [demand] dipped initially when everyone – it’s hard to remember back to March 2020 – everyone was terrified to do anything – so it definitely dipped a little bit – then it’s increased, then it sort of steadied, but it’s increased – demand is higher than it ever was pre COVID now – I’m just spread across everywhere!

Interview 27, GP

Despite interviewees reporting that patients can be satisfied with receiving care remotely, external influences – such as the media and changes in policy, particularly those aspects focused on seeing patients face-to-face – were mentioned to have contributed towards a challenging environment for practices. Several participants felt that the criticism from media outlets around patients receiving consultations remotely had been demoralising and frustrating for GPs. This challenge has also been noted nationally and is not unique to our study. For example, the BMA called for action from the Health Secretary to reduce negative media against primary care due to concerns over further exacerbating the issues with staff recruitment and retention. 60

I guess probably towards the end of last year I think when there was lots of negative media coverage where there were some very vocal patients, very demanding about face-to-face appointments but the vast majority [of patients], in my experience now, are happy to consult remotely.

Interview 9, Digital First Primary Care company stakeholder and GP

How Digital First Primary Care is implemented and used within primary care

Digital First Primary Care was conceptualised differently across practices, including those embedded within the same super-partnership, which subsequently altered how Digital First Primary Care platforms were introduced. The most common characteristic of the implementation of Digital First Primary Care was that every initial contact made by any patient, including those living with multiple long-term conditions, with a healthcare professional in general practice was via a digital medium, such as an online platform directed by answering a series of questions. Subsequent interactions with a patient after this initial contact could then be online (e.g. messaging via a Digital First Primary Care platform), by phone, in-person or, rarely, by video.

The primary rationale that practices reported for introducing Digital First Primary Care (other than governmental policy mandating its use during the pandemic) was to manage patient demand and reduce the need for face-to-face appointments for every patient query. Hence, it was not solely about improving access for patients to general practice services. While remote care was beneficial in preventing COVID-19 transmission during the pandemic, many aspects of Digital First Primary Care have been retained since the pandemic as a result of the other potential benefits it offered.

As mentioned in Chapter 1, there are multiple different Digital First Primary Care systems available for practices to use, each offering slightly different approaches. Some practices in our sample considered switching Digital First Primary Care providers to better suit the needs of the practice and their patients (e.g. to better integrate with existing digital systems or to have better triaging ability or increased accessibility for patients). Others changed Digital First Primary Care platforms as a result of governance decisions within their super-partnership. Some participants questioned the lack of available and robust evidence on the advantages and drawbacks of the different Digital First Primary Care providers’ systems, which made it difficult for general practices to make decisions about which platforms to adopt given their workforce composition, the administrative support available and the needs of their patients.

Some of that sort of bedding down after all the franticness of COVID, would be quite helpful. And I think I would choose to prioritise that rather than the next new tech thing, because I’m worried about layering on too much stuff, and then the whole thing just collapsing.

Interview 18, national policy-maker

The introduction of Digital First Primary Care was sometimes accompanied by the application of other digital approaches, including platforms which enabled practice staff to text message patients. Using these additional digital approaches, patients could reply to the practice by providing a response to a request (e.g. providing an image) but were unable to initiate contact themselves (unlike with Digital First Primary Care systems). In addition, staff from several practices discussed how they were able to embed Digital First Primary Care as part of another digital system to create a more user-friendly platform that could be bespoke for each practice. This also allowed the incorporation of more information relevant to patient self-management; for instance, signposting patients to relevant health-related and self-help websites.

With the onset of the COVID-19 pandemic, staff across general practice were faced with a scenario where there was very little time between being aware of the widespread introduction of Digital First Primary Care and its implementation, with little information and training offered to support implementation.

I think that it’s almost like there was no [Digital First Primary Care system] and then suddenly there is, so we created a tsunami of workload.

Interview 4, GP

The volume of enquiries submitted using Digital First Primary Care varied across our sample. Monday was often reported as being the busiest day of the week due to a backlog of enquiries sent by patients over the weekend. Most patient queries were addressed within 24–48 hours of submission. Even where practices were using Digital First Primary Care prior to the pandemic, its application was scaled up dramatically when the pandemic ensued. This is reflected in national data analyses during the pandemic which indicate large increases in the number of remote consultations across the country. 7

So on a Monday we’ll do 60 and then the other days we’ll make capacity for 30 on each of those days and I think that’s been pretty stable in terms of the numbers coming through.

Interview 19, GP

One of the most significant methods adopted by general practices to manage the high (often unmanageable) number of Digital First Primary Care enquiries from patients was to alter when the service was available for patients to access. Hence, practices adopted an approach of both a planned and ad hoc reduction of hours when Digital First Primary Care was available; for example, during times of high pressure or during weekends and bank holidays to ease the pressure on Monday mornings. Instead, patients needed to contact the practice by phone during these times. However, some argued that this approach only reduces the number of patients the practice is aware of, it does not mean these patients no longer need care, and so the demand for health care may not actually change overall.

But we cap it [number of Digital First Primary Care queries from patients] at a certain point. So, past 40 to 45, just from a safety point of view where … unless something urgent, you know, that is contact by reception or the hospital or somebody will contact us just so that because initially we didn’t have a cap and we were getting severe burnout from all clinicians.

Interview 17, GP

There was an absence of standardisation regarding Digital First Primary Care availability even where practices were part of the same super-partnership. For example, one practice may receive nearly all their patient contact digitally, while others only have the Digital First Primary Care system available for a certain period during the day (e.g. 9–11 a.m.), whereas others may have a designated number of Digital First Primary Care consultations scheduled for a given day or week completed by a single GP. Altering the hours of access was seen as an effective method to allocate work across clinical and non-clinical staff working in the practice, as well as remotely, which was felt to help prevent staff burnout and improve patient safety.

The introduction and use of Digital First Primary Care during the COVID-19 pandemic

All practices within our sample were using Digital First Primary Care in some capacity prior to the COVID-19 pandemic; however, its use was not widespread, and practices were quite pragmatic about its application relevant to clinician expertise and administration support to underpin the roll out of the system. Some practices took steps to work with the providers of Digital First Primary Care to prepare staff for roll out, as well as patients with respect to engagement. For example, some clinicians cited how they worked with Digital First Primary Care providers to manage new workflows and adapt their working culture and behaviour to make the best use of Digital First Primary Care post implementation.

[I’m] not really sure how it was introduced, as in how it came about to the practice, but it was just introduced to us – I think we had a training session on it, at a whole practice meeting, and just an explanation on what could be used, and how they were triaged, for reception and stuff.

Interview 3, nurse

However, this was not the case for all practices, where, as mentioned earlier, the introduction of Digital First Primary Care during the pandemic was often more rushed in order to quickly reduce footfall in the practice, with less time and capacity available to consider the optimal way of introducing the new approach.

We needed to kind of find a way of managing the situation we were in with COVID … This wouldn’t have happened if COVID hadn’t happened … it’s shoved everyone kind of five years on almost in terms of this technology. So it was a way of trying to manage what was going on and try to manage patients, how to give them some access in a way that made sense really.

Interview 2, GP

During the height of the pandemic, and more recently, staff felt that more patients were finding telephone and video consultations more acceptable but understood that this was heavily dependent on the digital literacy of patients and the health issue at hand (see Impact of Digital First Primary Care on patients). Other studies have found similar preferences for digital/remote consultations among patients (e.g. Clarke et al. 202215). The introduction of Digital First Primary Care also meant fewer patients entering general practices physically, which helped manage COVID-19 infections and protected staff working in the practice.

Impacts of Digital First Primary Care on patients with multiple long-term conditions

Several advantages and disadvantages for patients were described in relation to the use of Digital First Primary Care. However, there are two points to note when outlining these findings. The first is that this data was only collected from GP staff and stakeholders; therefore, the impacts described here are those that are perceived to have occurred by these individuals (rather than being described directly by patients themselves). Secondly, some of these impacts do not specifically relate to patients with multiple long-term conditions, they also apply to patients more generally. However, we highlight specific information in relation to patients with multiple long-term conditions where available.

The impact of Digital First Primary Care on carers of those with multiple long-term conditions

For those with multiple long-term conditions, carers can be a key source of support and will be involved in their care coordination, and so may also be impacted by Digital First Primary Care. The participants discussed the impact of Digital First Primary Care approaches for carers of those with multiple long-term conditions, both in terms of the benefits and challenges it offered. As with the previous section on patient impacts, this section represents the perceived impacts on carers as described by practice staff and stakeholders, rather than those described directly by carers.

The impact of Digital First Primary Care on healthcare professionals caring for patients with multiple long-term conditions

The introduction of Digital First Primary Care approaches, by its nature, changed the way in which healthcare professionals work, both individually and with each other, and changed the nature of the healthcare professional–patient relationship. Digital First Primary Care was reported by the participants to both support and hinder these aspects in different ways. Staff noted in particular the importance of developing strong relationships with patients with multiple long-term conditions given their complexity and greater need for continuity of care.

Summary of the main findings of the study

In this section the main findings of the study are summarised, ahead of the Discussion and conclusions.

The aim of this evaluation was to explore the experiences of Digital First Primary Care for patients with multiple long-term conditions from the perspectives of health professionals and stakeholders. Here, we provide an overview of the key study findings.

Overall, the COVID-19 pandemic led to the rapid adoption of Digital First Primary Care on a larger scale than pre pandemic. The roll out was done at speed and there was little opportunity for healthcare professionals to reflect on the impact on patient groups, such as those with multiple long-term conditions. Nor has much consideration been given to the impacts that the widespread use of these approaches may have on the healthcare professionals who provide care for those with multiple long-term conditions.

Choosing a Digital First Primary Care provider and implementing the change could be a challenge for practices, and the way in which a practice implemented the Digital First Primary Care approach could adversely impact those with multiple long-term conditions for example in assisting or hindering continuity of care. The introduction of Digital First Primary Care was frequently cited by participants as leading to an increase in patient demand. To manage this, multiple practices reported reducing the time the system was available for use (e.g. closing it down over weekends).

Patients with multiple long-term conditions could face additional challenges with the use of Digital First Primary Care compared to other patients. These challenges included navigating Digital First Primary Care systems, particularly digital questionnaires which followed algorithmic approaches and restricted the opportunity for descriptive narrative and speaking with a professional who knew them and their conditions well. Alternatively, Digital First Primary Care could offer additional benefits to patients with multiple long-term conditions, such as greater convenience and easier completion of simple tasks, such as repeat prescriptions. However, these benefits were, in part, determined by the nature and severity of the patient’s condition(s).

The presence of multiple long-term conditions was not the only factor which could impact upon the ease of use of a Digital First Primary Care approach. Other factors noted by the interview respondents included patients for whom English was not their first language, literacy skills, confidence in navigating online services (often perceived by the participants to be correlated with the age of the patient) and the availability of technology to engage with the practice this way.

There were differing views from the participants as to the extent to which Digital First Primary Care helped to manage staff workload. For some it did, particularly for straightforward tasks such as sick notes. But for other conditions or patient groups, the efficiency of the system was often questioned, for example for use with patients with multiple long-term conditions where the digital form may not fully or accurately inform the health professional about the problem, leading to inefficiencies.

Several participants noted a preference from staff to see patients face-to-face, particularly those with multiple long-term conditions. For many, a face-to-face consultation was not just seen as a transactional consultation but a chance to assess the patient more holistically. Some felt that once a relationship between a healthcare professional and a patient with multiple long-term conditions had been established, other forms of consultation could be used, for example a telephone consultation or messaging via a Digital First Primary Care platform.

The participants identified benefits of Digital First Primary Care to carers of those with multiple long-term conditions, particularly the ability to be more involved in consultations with healthcare professionals and the care of the patient. However, some concerns around confidentiality and privacy were raised. Carers’ experiences of Digital First Primary Care have, until now, been relatively overlooked, and this represents an area where further research could be of benefit.

Discussion of the findings

In this section of the report, the key findings from this rapid evaluation are examined in greater detail and in the context of previous research. The implications for practice are also explored, and the strengths and weaknesses of the approach are noted.

What lessons can be learnt for future practice of Digital First Primary Care for patients with multiple long-term conditions?

Here we address our final research question by considering the lessons which can be learnt for the future use of Digital First Primary Care approaches for patients with multiple long-term conditions across a range of stakeholders. The lessons at general-practice level may also be useful for other groups.

Strengths and weaknesses of the approach

Digital First Primary Care has become a popular approach used by general practice during and since the COVID-19 pandemic, so this project has focused on an issue of central importance to primary care at the current time and contributes to the discussion of how general practice adapts to this period post the COVID-19 pandemic. The focus of this rapid evaluation was on the impacts on patients with multiple long-term conditions, from the perspectives of stakeholders and health professionals, of Digital First Primary Care. Information on the impacts on patients with multiple long-term conditions was largely not present in the published literature. The findings also identify issues for the carers of patients with multiple long-term conditions, as noted by stakeholders and health professionals, a group often neglected in previous research.

The key weakness of this study was that the research team were not able to obtain the views of patients with multiple long-term conditions and their carers. The research team recruited fewer healthcare professional interviewees (n = 14) than had originally been planned. The study is limited to eight general practices and the use of two digital providers. The participants were not able to identify specific combinations of multiple long-term conditions for which Digital First Primary Care was a challenge.

Due to the challenges of recruiting general practice staff, additional interviews were conducted with stakeholders who also worked in general practices. Despite seeking to do so, the researchers were not able to include the views of a range of allied health professionals within primary care in this study. GPs formed the majority of participants interviewed; however, this may reflect the fact that the majority of Digital First Primary Care approaches were led by GPs. Several of the general practices recruited to the study were from one super-partnership. Therefore, their experiences may be aligned compared to other practices who are not within a super-partnership. Fortunately, the research team were experienced in qualitative approaches and primary care research and were, therefore, able to adapt the approach as needed when faced with recruitment challenges.

Despite the recruitment challenges faced, we believe we have collected useful data and distilled learning on the experiences, advantages and disadvantages of using Digital First Primary Care approaches for patients with multiple long-term conditions. The interviews with stakeholders provide insights into the current national primary care context and digital-related policy. The findings from this study remain timely given the ongoing Digital First Primary Care implementation and policy challenges, as well as the pressures on primary care.

Conclusions

Despite a large volume of the consultations in general practice taking place with patients with multiple long-term conditions, the roll-out of Digital First Primary Care, particularly during the COVID-19 pandemic, did not specifically address the needs of patients with multiple long-term conditions. Nor has there been consideration of the use of these approaches by the health professionals who care for patients with multiple long-term conditions. This includes the efficiency of the system and the ways in which it addresses the needs of this patient population.

The findings of our rapid evaluation suggest that those interviewed feel there may be benefits associated with Digital First Primary Care approaches for the carers of those with multiple long-term conditions, a group which up until now have been largely absent from the literature on Digital First Primary Care approaches. Future work should seek to include the views of Digital First Primary Care of patients with multiple long-term conditions and their carers, which was not possible in this study due to challenges with capacity within general practice. This study highlights how general practice has developed and adapted swiftly over the last few years and how little is known about the impacts of Digital First Primary Care. A mixed methods longitudinal study or economic evaluation of its impacts could be potential ways to understand the impacts of these changes more comprehensively.

Equality, diversity and inclusion

Patient and public involvement

During the scoping stage of the study, a workshop to discuss the evaluation design and shape the research questions was held with members of the BRACE Health and Care panel, which included members of the BRACE PPI panel. As a result of the workshop, several changes were made to the protocol, including having more of a focus on access to digital approaches in primary care. The evaluation protocol was also reviewed by two members of the BRACE PPI panel.

Through online meetings, workshops and via e-mail, members of the group have continued to be involved, including by sharing feedback on how best to recruit participants, developing interview guides and interpreting and providing feedback on the findings. Discussion regarding the challenges of recruiting both patients and staff were discussed extensively at each BRACE steering group meeting (n = 3), with representatives from the PPI panel. The steering group, alongside the PPI panel, put forward suggestions of how the team could bolster recruitment, in particular by approaching super-partnerships and federations. A ‘Plain English’ summary of the final report has also been reviewed by two members of the BRACE PPI panel. We will seek the advice of the BRACE PPI panel regarding how best to communicate the findings of the evaluation to patient and public audiences.

The initial protocol for this study included further patient and public involvement with a plan to undertake interviews with patients and/or carers to understand their experiences of using Digital First Primary Care approaches. However, due to challenges in recruitment this was not possible.

Acknowledgements

We would sincerely like to thank all the participants in this study and our contacts at practices who helped to coordinate some of the interactions with interviewees. We would also like to thank everyone who gave their time to support the project, including stakeholders from the two digital providers the study focused on and from the super-partnership. We recognise that the point during which we conducted this study was a time of extreme pressure on primary care; therefore, we are very grateful that, despite this, staff still found time to support and contribute to our study.

We would also like to thank our BRACE colleagues and members of the BRACE steering group, Health and Care panel and User Involvement group for their constructive feedback and input throughout the study: Professor Russell Mannion and Professor Judith Smith (both University of Birmingham) for undertaking a critical review of the draft of the report; Cathy Dakin and Ann Evans (BRACE Centre senior research administrators) for providing varied and valued support throughout; and two members of our User Involvement group for reviewing our Plain language summary of the report. Particular thanks to Dilwyn Sheers (NHSE), Geraldine M Clarke, Richard Brine and Emma Vestesson (The Health Foundation) who have discussed the project during its lifetime with the PI (JN).

Contributions of authors

Jennifer Newbould (https://orcid.org/0000-0002-2602-6984) (Research Leader) was the principal investigator for the study. She conducted the scoping work for this project and conceived the content and design of the study, led the data collection, conducted stakeholder interviews and led the overall data analysis. She led the writing of Chapter 5 and contributed to all other chapters. She provided a critical review of the final report and is the guarantor and corresponding author.

Lucy Hocking (https://orcid.org/0000-0002-8319-962X) (Senior Analyst) was the project manager for this study and contributed to the conception and design of the study, the data collection with practices and the overall data analysis and interpretation. She contributed to the final report, leading the writing of Chapter 2, co-writing and then leading Chapter 4 and supporting the writing of Chapter 5.

Manbinder Sidhu (https://orcid.org/0000-0001-5663-107X) (Associate Professor) contributed to the conception and design of the study, the data collection with practices and the overall data analysis and interpretation. He also contributed to the final report, leading the writing of Chapter 3, co-writing Chapter 4 and supporting the writing of Chapter 5.

Kelly Daniel (née Singh) (https://orcid.org/0000-0002-4513-1026) (Evaluation Fellow) contributed to the overall data analysis and interpretation. She also contributed to the final report, leading the writing of Chapter 1, supporting the writing of Chapters 2 and 5 and co-writing Chapter 4.

All authors contributed to integrating the findings of the study. Jennifer Newbould made critical revisions to the report for important intellectual content and approved the final manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved.

Disclosure of interests

Full disclosure of interests: Completed ICMJE forms for all authors, including all related interests, are available in the toolkit on the NIHR Journals Library report publication page at https://doi.org/10.3310/AWBT4827.

Primary conflicts of interest: None

Data-sharing statement

Data from the interviews will be accessible to the participants who took part in this rapid evaluation following GDPR, RAND Europe and University of Birmingham data protection guidelines upon request. All requests should be sent to the corresponding author in the first instance. To protect the anonymity of interviewees, the data are not publicly available. Further information can be obtained from the corresponding author.

Ethics statement

Ethical approval was obtained from the University of Birmingham Humanities and Social Sciences Ethical Review Committee in September 2021 (ERN_13-1085AP35, see project documents).

Information governance statement

The University of Birmingham is committed to handling all personal information with regard to all qualitative data in line with the UK Data Protection Act (2018) and the General Data Protection Regulation (EU GDPR) 2016/679.

Department of Health and Social Care disclaimer

This publication presents independent research commissioned by the National Institute for Health and Care Research (NIHR). The views and opinions expressed by the interviewees in this publication are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, MRC, NIHR Coordinating Centre, the HSDR programme or the Department of Health and Social Care.

This monograph was published based on current knowledge at the time and date of publication. NIHR is committed to being inclusive and will continually monitor best practice and guidance in relation to terminology and language to ensure that we remain relevant to our stakeholders.

Disclaimers

This article presents independent research funded by the National Institute for Health and Care Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the HSDR programme or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, the HSDR programme or the Department of Health and Social Care.

Topic guide for health professionals

• Reasons for changing to a Digital First Primary Care approach and proportion of consultations through Digital First Primary Care, including the impact and legacy of COVID-19 on how practices use Digital First Primary Care.

  1. – Describe how the Digital First Primary Care approach was introduced?

  2. – Who was involved? How were decisions made and against what criteria?

  3. – Explain the reasoning behind the provider selected to deliver primary care services?

  4. – How many consultations are being delivered using this new platform? How has this changed from pre, during and, more lately, as a result of the pandemic?

• Have members of staff received any training on delivering Digital First Primary Care?

  1. – What training did they receive? How many hours?

  2. – Attitudes towards training? Is further/repeat training required? If yes, describe the nature of training desired?

• Are there particular groups of patients the Digital First Primary Care approach favours? Are there groups which don’t use it? (With particular focus on underserved communities.)

  1. – Repeat users?

  2. – Those who do not engage? Those who had reservations and are now frequent users?

  3. – Younger cohort? Those living with long-term conditions?

• Are there particular conditions, or combinations of conditions, that the Digital First Primary Care approach favours or is less appropriate for?

  1. – Impact on the nature of relationships developed and rapport generated amongst certain patients?

  2. – How do consultations across groups differ?

• Are there particular advantages/disadvantages of the approach for patients with multiple long-term conditions?

  1. – Better understanding of needs and enhanced engagement?

• Differences in workflow with the use of Digital First Primary Care (e.g. impacts on demand, perceptions of re-consultation rates, impacts on DNAs and on homes visits).

• Impacts on the GP practice (e.g. change in registered number of patients, prescribing, staffing, work pattern, work location, issues of staff retention and recruitment).

• Staff satisfaction/challenges.

  1. – Staff job satisfaction changed since introduction?

  2. – Greater pressure to do with greater number of contacts across different platforms?

• Perceptions of impacts on patient care (e.g. are diagnoses made more quickly, is the patient pathway more or less efficient, do the notes ahead of patient contact aid or hinder the consultation)—with a particular focus on patients with multiple long-term conditions.

• Is there anything else we have not covered that you would like to tell me about?

Topic guide for stakeholders

• Can you tell me about your role?

  1. – Do you have a dual role? Are you a practising clinician?

  2. – Have you done particular work in digital primary care?

• Thinking about digital approaches in primary care what are your views on using these in primary care at the current time?

  1. – Prompt: pros/cons

• Are there particular advantages/disadvantages of digital-first approaches in primary care for patients with multiple long-term conditions?

  1. – Prompt: pros/cons

• Thinking from the perspective of patients, how do digital approaches to primary care impact on patients with multiple long-term conditions?

  1. – Speed of access to see or speak to a clinician?

  2. – Which clinician is seen?

  3. – Continuity of care?

• Thinking from the perspective of health professionals, how do digital approaches to primary care impact on the care they can provide to patients with multiple long-term conditions?

  1. – Speed of access to see or speak to a clinician?

  2. – Which clinician is seen?

  3. – Continuity of care?

• Are there particular conditions, or combinations of conditions, that the Digital First Primary Care approach favours or is less appropriate for?

  1. – Older patients? Those without access to digital means?

• We know that some patients with multiple long-term conditions will want to consult with their carers. Do digital approaches present challenges to this?

  1. – How are these overcome?

• Thinking more generally about Digital First Primary Care now and less about those with multiple long-term conditions, do you feel Digital First Primary Care impacts on patient care? In what ways?

  1. – Are diagnoses made more quickly, is the patient pathway more or less efficient, do the notes ahead of patient contact aid or hinder the consultation?

• What do you think has been the impact of COVID-19 on digital approaches to primary care?

• Thinking about where we are in the pandemic now, how do you see the future for general practice with the use of digital approaches?

  1. – Will the balance change? Will face-to-face become the norm or is digital here to stay?

• Is there anything else that we have not covered that you would like to add?