Background: United Kingdom general practices transitioned rapidly to remote-by-default services in 2020 and subsequently considered whether and how to continue these practices. Their diverse responses provided a unique opportunity to study the longer-term embedding, adaptation and abandonment of digital innovations. Research questions: What was the range of responses to the expansion of remote and digital triage and consultations among United Kingdom general practices in the period following the acute phase of the coronavirus disease discovered in 2019 (COVID-19) pandemic? What can we learn from this example about the long-term impacts of crisis-driven sociotechnical change in healthcare settings?
Methods: We collected longitudinal data from 12 general practices from 2021 to 2023, comprising 500 hours of ethnographic observation, 163 interviews in participating practices and linked organisations (132 staff, 31 patients), 39 stakeholder interviews and 4 multi-stakeholder workshops (210 participants), with additional patient and public involvement input. Data were de-identified, uploaded to NVivo (QSR International, Warrington, UK) and synthesised into case studies, drawing on theories of organisational innovation.
Results: General practices' longitudinal progress varied, from a near-total return to traditional in-person services to extensive continuing use of novel digital technologies and pathways. Their efforts to find the right balance were shaped and constrained by numerous contextual factors. Large size, slack resources, high absorptive capacity, strong leadership and good intrapractice relationships favoured innovation. Readiness for remote and digital modalities varied depending on local tension for change, practice values and patient characteristics. Technologies' uptake and use were influenced by their material properties and functionality. Embedding and sustaining technologies required ongoing work to adapt and refine tasks and processes and adjust (or, where appropriate, selectively abandon) technologies. Adoption and embedding of technologies were affected by various staff and patient factors. When technologies fitted poorly with tasks and routines or when embedding efforts were unsuccessful, inefficiencies and 'techno-stress' resulted, with compromises to patient access and quality of care.
Limitations: Sampling frame was limited to United Kingdom and patient interviews were relatively sparse.
Conclusion: There is wide variation in digital maturity among United Kingdom general practices. Low use of remote and digital technologies and processes may be warranted and reflect local strategic choices, but it may also indicate lack of awareness and a reactive rather than strategic approach to digital innovation. We offer an updated typology of digital maturity in general practice with suggestions for tailored support.
Future work: The typology of digital maturity could be applied further to identify in more detail the kind of support needed for practices that are at different stages of maturity and are serving different populations. The need for strategically traditional practices in deprived settings should also be explored.
Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR132807.
Keywords: CASE STUDY; E-CONSULTATIONS; GENERAL PRACTICE; INNOVATION; QUALITATIVE RESEARCH; REMOTE CONSULTATIONS; REMOTE TRIAGE; ROUTINISATION; WORKFORCE.
Before 2020, most general practice appointments were in-person. In March 2020, for infection control reasons, people had to phone or go online to seek appointments, and most consultations became remote (phone, video or electronic message). We studied how United Kingdom general practices took these ‘disruptive innovations’ forward (or not). We used ethnography, where a researcher spends time in a practice observing and interviewing staff and patients. We followed 12 practices (from small to large, basic to advanced technologically, and in affluent to deprived localities) from 2021 to 2023. We collected additional data from workshops, publicly available reports and wider interviews. By 2023, the 12 practices ranged from ‘strategically traditional’ (typically, serving populations with complex needs, for whom in-person services were often more appropriate) to ‘digital trailblazers’ (making extensive use of digital tools and delivering > 50% of consultations remotely). Digitalisation increased complexity of care. Staff reported stress (‘it feels like a call centre’), low confidence and unmet training needs. Almost all digital innovations require an extensive period of embedding to adjust processes and pathways to fit the technology and vice versa. Measures to mitigate inequities (e.g. training patients, digital navigators, walk-in services, low-tech options such as text messaging) sometimes helped. The prevailing context of austerity, workforce shortages, rising demand and need, and high workload made routinisation of digital innovations challenging. One size does not fit all. While some practices are appropriately high-tech, there are sometimes good reasons why others are not. Support for practices should focus on resourcing and optimising digital embedding, mitigating patient inequities and ensuring staff competence and wellbeing.