Talking in primary care (TIP): protocol for a cluster-randomised controlled trial in UK primary care to assess clinical and cost-effectiveness of communication skills e-learning for practitioners on patients' musculoskeletal pain and enablement.

INTRODUCTION: Effective communication can help optimise healthcare interactions and patient outcomes. However, few interventions have been tested clinically, subjected to cost-effectiveness analysis or are sufficiently brief and well-described for implementation in primary care. This paper presents the protocol for determining the effectiveness and cost-effectiveness of a rigorously developed brief eLearning tool, EMPathicO, among patients with and without musculoskeletal pain. METHODS AND ANALYSIS: A cluster randomised controlled trial in general practitioner (GP) surgeries in England and Wales serving patients from diverse geographic, socioeconomic and ethnic backgrounds. GP surgeries are randomised (1:1) to receive EMPathicO e-learning immediately, or at trial end. Eligible practitioners (eg, GPs, physiotherapists and nurse practitioners) are involved in managing primary care patients with musculoskeletal pain. Patient recruitment is managed by practice staff and researchers. Target recruitment is 840 adults with and 840 without musculoskeletal pain consulting face-to-face, by telephone or video. Patients complete web-based questionnaires at preconsultation baseline, 1 week and 1, 3 and 6 months later. There are two patient-reported primary outcomes: pain intensity and patient enablement. Cost-effectiveness is considered from the National Health Service and societal perspectives. Secondary and process measures include practitioner patterns of use of EMPathicO, practitioner-reported self-efficacy and intentions, patient-reported symptom severity, quality of life, satisfaction, perceptions of practitioner empathy and optimism, treatment expectancies, anxiety, depression and continuity of care. Purposive subsamples of patients, practitioners and practice staff take part in up to two qualitative, semistructured interviews. ETHICS APPROVAL AND DISSEMINATION: Approved by the South Central Hampshire B Research Ethics Committee on 1 July 2022 and the Health Research Authority and Health and Care Research Wales on 6 July 2022 (REC reference 22/SC/0145; IRAS project ID 312208). Results will be disseminated via peer-reviewed academic publications, conference presentations and patient and practitioner outlets. If successful, EMPathicO could quickly be made available at a low cost to primary care practices across the country. TRIAL REGISTRATION NUMBER: ISRCTN18010240.

Experiences of remote consultation in UK primary care for patients with mental health conditions: A systematic review.

Objectives: There has been a rapid shift from face-to-face to remote consultation across healthcare settings. 90% of patients with mental health conditions are cared for entirely in primary care. Remote consultation can present challenges and benefits for patients with mental health conditions. The aim of this systematic review was to collate and examine the evidence relating to remote consultation in UK primary care on the experiences of patients with mental health conditions. Methods: Six major databases were searched for empirical studies published in the English language between 1 January 2010 and 21 October 2022. Studies were included where remote consultation occurred between a patient and primary care clinician. Outcomes of interest include mode of remote consultation, patient experiences and characteristics. Final included studies were assessed for quality, and results analysed with narrative synthesis. Results: Six studies met the inclusion criteria, covering a range of mental health conditions and remote consultation modalities (telephone, video, online, email, text-based). Patients were overall satisfied with remote consultation, with particular benefit for certain mental health conditions or anxious patients. However, several studies found that face-to-face was the preferred method, with highlighted negatives to remote consultation, such as inflexibility of online formats. Acceptability of remote consultation is context specific and influenced by the purpose of the consultation and individual patient. Remote consultation may reduce anxiety in some patients, but is potentially less acceptable than face-to-face for relational appointments. Conclusions: Acceptability of remote consultation is context dependent. There is a lack of evidence surrounding patient characteristics and access to remote consultation.

Guidelines and recommendations about virtual mental health services from high-income countries: a rapid review.

OBJECTIVES: This study reviewed existing recommendations for virtual mental healthcare services through the quadruple aim framework to create a set of recommendations on virtual healthcare delivery to guide the development of Canadian policies on virtual mental health services. DESIGN: We conducted a systematic rapid review with qualitative content analysis of data from included manuscripts. The quadruple aim framework, consisting of improving patient experience and provider satisfaction, reducing costs and enhancing population health, was used to analyse and organise findings. METHODS: Searches were conducted using seven databases from 1 January 2010 to 22 July 2022. We used qualitative content analysis to generate themes. RESULTS: The search yielded 40 articles. Most articles (85%) discussed enhancing patient experiences, 55% addressed provider experiences and population health, and 25% focused on cost reduction. Identified themes included: screen patients for appropriateness of virtual care; obtain emergency contact details; communicate transparently with patients; improve marginalised patients' access to care; support health equity for all patients; determine the cost-effectiveness of virtual care; inform patients of insurance coverage for virtual care services; increase provider training for virtual care and set professional boundaries between providers and patients. CONCLUSIONS: This rapid review identified important considerations that can be used to advance virtual care policy to support people living with mental health conditions in a high-income country.

Evidence for Access: Systematic Scoping Review of Access Systems in General Practice.

BACKGROUND: Access to GP appointments is increasingly challenging in many high-income countries, with an overstretched workforce and rising demand. Various access systems have been developed and evaluated internationally. AIM: We aimed to systematically consolidate the current international evidence base related to different types of GP access systems. DESIGN AND SETTING: A scoping review examining international literature. METHOD: Literature searches were run across relevant databases in May 2022. Title, abstract and full text screenings were carried out. Data from included studies were extracted and mapped to synthesise the components and aims within different GP access systems. RESULTS: 49 studies were included in the review. The majority of these were set in the UK. Some access systems featured heavily in the literature, such as Advanced Access, telephone triage and online consultations, and others less so. There were two key strategies adopted by systems which related to either changing appointment capacity or modifying patient pathways. Components related to these strategies are summarised and illustrated as a schematic representation. Most rationales behind access systems were practice, rather than patient, focused. 'Add on' systems and aims for efficiency became more popular in recent years. CONCLUSION: The synthesis provides a useful tool in understanding access systems' aims, design, and implementation. With focus on alleviating demand, patient-focused outcomes appear to be under investigated and potentially overlooked during design and implementation. More recently, digital services are promoted as offering patient choice and convenience. But a context where demand outweighs resources challenges the premise that extending choice is possible.

Interpreting technology: Use and non-use of doctor-patient video consultations in Danish general practice.

This study uses socio-cognitive theory on technological frames to understand how and why general practitioners in Denmark use or choose not to use video consultations. Video consultations play a vital role in the digitalisation of the Danish healthcare system. Whilst political decision-makers continuously push for increased use of video consultations, uptake accounts for less than 2% of all consultations. Research is needed that explores the actual circumstances and conditions of video consultation use. Our data corpus consists of 30 semi-structured interviews conducted from August 2021 to August 2022 with 27 Danish general practitioners. Interviews were analysed following reflexive thematic analysis. Our findings show that video consultations are interpreted as 1) compromising occupational values, 2) a crisis tool, 3) the future, and 4) a tool to improve work conditions. Video consultations are differently adopted across clinics due to different interpretations of the technology and its relative advantage in specific clinical contexts. We argue that the concept of technological frames offers a useful analytic perspective for elucidating and anticipating attitudes and actions towards a technology. It increases our understanding of the uptake and rejection of video consultations. This knowledge is valuable for clinicians and politicians working with technological innovation in general practice.

Training primary care staff in delivering the primary care consultation remotely: a systematic review.

BACKGROUND: Remote consultation is widely used in primary care, and its use has increased greatly since the onset of the COVID-19 pandemic. Despite this, primary care clinicians lack formal training in delivering remote consultation. There is a need to understand how training might best be delivered, and what evidence there is to support this. AIM: To summarise existing published literature about training primary care staff in conducting primary care consultation remotely, to outline which models of training may be effective, and to identify unanswered questions for future research. DESIGN & SETTING: Systematic review of English language studies in primary care included in Medline (Ovid), Cochrane Database, PubMed, Embase (Ovid), Web of Science, and CINAHL from 2010-2021; and in Google results from 2010-2022. METHOD: Databases were searched using a predefined search strategy. Title, abstract, and full-text screening was conducted to identify eligible studies for inclusion in the review. The quality of included studies was assessed, and findings were synthesised to answer the research questions. RESULTS: We included 10 studies. Seven examined training on remote consultation with trainee GPs or residents, and three examined training on remote consultation with qualified primary care clinicians. Training described led to positive change overall, including increased confidence and self-efficacy in delivering remote consultations. Furthermore, trainees reported increased use of remote consultation, increased efficiency, and increased engagement from patients. Studies where training involved workshops or didactic learning alongside experiential learning resulted in more positive feelings and more confidence about how technology could aid consultations. CONCLUSION: There is limited evidence on training primary care staff in conducting remote consultation. Available evidence indicates that training has a positive impact on the ability of clinicians and staff to deliver remote consultation.

Clinician-led secondary triage in England's urgent care delivery: a cross-sectional study.

BACKGROUND: Clinician-led secondary triage, following primary triage by the NHS 111 phone line, is central to England's urgent care system. However, little is known about how secondary triage influences the urgency attributed to patients' needs. AIM: To describe patterns of secondary triage outcomes and call-related factors (such as call length and time of call) associated with upgrading/downgrading of primary triage outcomes. DESIGN AND SETTING: Cross-sectional analysis of secondary triage call records from four urgent care providers in England using the same digital triage system to support clinicians' decision making. METHOD: Statistical analyses (mixed-effects regression) of approximately 200 000 secondary triage call records were undertaken. RESULTS: Following secondary triage, 12% of calls were upgraded (including 2% becoming classified as emergencies) from the primary triage urgency. The highest odds of upgrade related to chest pain (odds ratio [OR] 2.68, 95% confidence interval [CI] = 2.34 to 3.07) and breathlessness (OR 1.62, 95% CI = 1.42 to 1.85; reference: abdominal pain) presentations. However, 74% of calls were downgraded; notably, 92% (n = 33 394) of calls classified at primary triage as needing clinical attention within 1 h were downgraded. Secondary triage outcomes were associated with operational factors (day/time of call), and most substantially with the clinician conducting triage. CONCLUSION: Non-clinician primary triage has significant limitations, highlighting the importance of secondary triage in the English urgent care system. It may miss key symptoms that are subsequently triaged as requiring immediate care, while also being too risk averse for most calls leading to downgrading of urgency. There is unexplained inconsistency between clinicians, despite all using the same digital triage system. Further research is needed to improve the consistency and safety of urgent care triage.

General practice experiences for parents of children with intellectual disability: a systematic review.

BACKGROUND: Parents of children diagnosed with intellectual disability are at increased risk of mental and physical health difficulties compared with other parents. They are likely to regularly seek medical treatment for their health concerns from general practice as well as on behalf of their child with intellectual disability, yet there is limited evaluation of the role general practice plays for this patient group. AIM: To explore parents' experiences of general practice support when caring for a child with intellectual disability. DESIGN & SETTING: Systematic review of studies reporting experiences of general practice as described by parents who care for children with intellectual disability. METHOD: Databases were searched using a pre-defined search strategy. Studies were included based on detailed inclusion criteria, title, abstract, and full-text screening. Quality assessment was conducted using the Mixed Methods Appraisal Tool (MMAT). A narrative synthesis was conducted. RESULTS: A total of nine studies were identified. There was a clear absence of data on parents' own health experience and consultation in general practice. Findings related to navigating general practice on behalf of their child's health including accessibility of general practice and positive and negative experiences of GPs. CONCLUSION: Findings from this review highlight priority areas for research, including further exploration of parents' perspectives on seeking support specifically for their own health concerns, while caring for a child with intellectual disability, to bring more awareness and understanding of the role general practice plays in supporting the health of this carer group. This review also considers implications for clinical services, including tailoring appointments for this patient group as a priority for continuity of care, which may result in improved experiences of general practice and encourage better communication.

Low Adoption of Video Consultations in Post-COVID-19 General Practice in Northern Europe: Barriers to Use and Potential Action Points.

In the wake of the COVID-19 pandemic, video consultation was introduced in general practice in many countries around the world as a solution to provide remote health care to patients. It was assumed that video consultation would find widespread adoption in post-COVID-19 general practice. However, adoption rates remain low across countries in Northern Europe, suggesting that barriers to its use exist among general practitioners and other practice staff. In this viewpoint, we take a comparative approach, reflecting on similarities and differences in implementation conditions of video consultations in 5 Northern European countries' general practice settings that might have created barriers to its use within general practice. We convened at a cross-disciplinary seminar in May 2022 with researchers and clinicians from 5 Northern European countries with expertise in digital care in general practice, and this viewpoint emerged out of dialogues from that seminar. We have reflected on barriers across general practice settings in our countries, such as lacking technological and financial support for general practitioners, that we feel are critical for adoption of video consultation in the coming years. Furthermore, there is a need to further investigate the contribution of cultural elements, such as professional norms and values, to adoption. This viewpoint may inform policy work to ensure that a sustainable level of video consultation use can be reached in the future, one that reflects the reality of general practice settings rather than policy optimism.

Online support groups for carers of people living with dementia: An investigation of videoconferencing support groups in lockdown.

BACKGROUND: This study aimed to explore the experiences of carers of people living with dementia who participated in videoconferencing support groups during the COVID-19 pandemic to investigate their preferences and experiences with online, hybrid, and face-to-face support. METHODS: This convergent mixed methods design study utilised an online questionnaire and semi-structured interviews. Interviews took place over videoconferencing software and were analysed through thematic analysis. Participants were recruited from support groups based in the UK and Ireland. RESULTS: 39 carers of people living with dementia completed the questionnaire and 16 carers participated in interviews. Participants found videoconferencing support groups more convenient, but face-to-face groups more enjoyable. Participants who had found it difficult to access face-to-face groups prior to COVID-19 expressed more positive perceptions of videoconference-based groups. Many felt that hybrid groups would make it easier for more people to attend. However, some carers described lacking the resources and technological skills to participate in online support groups effectively. Some suggested making IT training available may improve the capacity of carers to access support online. CONCLUSION: Videoconferencing support groups can be an appropriate way of supporting carers of people with dementia, especially for those who do not have access to face-to-face support groups. However, face-to-face support remains important to carers and should be made available when it can be implemented safely. Hybrid support groups could allow for increased accessibility while still providing the option of face-to-face contact for those who prefer it or are not adept with technology.

Older patients' experiences of access to and use of e-consultations with the general practitioner in Norway: an interview study.

OBJECTIVE: To explore older patients' experiences with accessing and using e-consultations to send text-based clinical inquiries to the general practitioner (GP) online. DESIGN: Qualitative study based on semi-structured interviews. Results were analysed through a six-phase thematic analysis and interpreted through Levesque's framework of patient-centred access to health care. SETTING: General practice in Norway. SUBJECTS: Patients aged over 65 years (n = 16) with experience in using e-consultations. RESULTS: Respondents considered e-consultations as an integrated part of general practice which helped them achieve better access to health care. We identified four themes describing older patients' access to and use of e-consultations: 1) the importance of digital health literacy to learn about and use the service - and the fear of losing it, 2) the high availability of the service as the main advantage, due to the perceived unavailability of physical GP services, 3) the importance of voluntary use of e-consultations, 4) the importance of a trusting relationship with the GP. IMPLICATIONS: Information about e-consultations and guidelines for suitable use are recommended to ensure equal access to all patients, regardless of their digital health literacy. Availability problems and high work burdens for the GPs could affect the patients' choice for using e-consultations. If e-consultations are used for triage purposes, caution should be taken to avoid a shift in workload from the health secretary to the GP.Key points of articleThe extended use of e-consultations with the general practitioner has raised concerns that the service may not be accessible and suitable for older patients.For older users, e-consultations can represent a positive addition to physical consultation forms due to the high availability of the service in a general practice setting characterised by long waiting times.Digital health literacy is essential to learn about and use the service. Information about the service and how to use it should be available to all patients to ensure equal access.A trusting relationship with the GP is described as essential for older patients to perceive the outcome of e-consultations as appropriate and safe.

Unintended consequences of patient online access to health records: a qualitative study in UK primary care.

BACKGROUND: Health systems are seeking to harness digital tools to promote patient autonomy and increase the efficiency of care worldwide. The NHS Long Term Plan created the right for patients to access 'digital first' primary care by 2023-2024, including online patient access to full medical records. AIM: To identify and understand the unintended consequences of online patient access to medical records. DESIGN AND SETTING: Qualitative interview study in 10 general practices in South West and North West England. METHOD: Semi-structured individual interviews with 13 patients and 16 general practice staff with experience of patient online access to health records. RESULTS: Online access generated unintended consequences that negatively impacted patients' understanding of their health care, with patients finding surprising or difficult to interpret information. Online access impacted GPs' documentation practices, such as when GPs pre-emptively attempted to minimise potential misunderstandings to aid patient understanding of their health care. In other cases, this negatively impacted the quality of the records and patient safety when GPs avoided documenting speculations or concerns. Contrary to assumptions that workload would be reduced, online access introduced extra work, such as managing and monitoring access, and taking measures to prevent possible harm to patients. CONCLUSION: The unintended consequences described by both staff and patients show that, to achieve the intended consequences set out in NHS policy, additional work is necessary to prepare records for sharing and to prepare patients about what to expect. It is crucial that practices are adequately supported and resourced to manage the unintended consequences of online access, now that it is the default position. A table of potential unintended consequences and mitigation measures is provided to aid practice managers and clinicians implementing online access.

Past, Present and Future: Perspectives on an Oral History of Intellectual Disability Nursing.

Thirty-one participants engaged in this oral history research study aimed at exploring the lived experience of intellectual disability nurses and healthcare assistants' knowledge of the trajectory of intellectual disability nursing over the last 30 years in the Republic of Ireland and England. This paper documents some of these experiences offering perspectives on intellectual disability nursing and what is important for the future. Findings from Ireland consider the nature of intellectual disability services and the registered nurse in intellectual disability. Findings from England focus on opportunities and restrictions in intellectual disability nursing, shared visions, the changing context within which work took place and also the internal and external supports that impacted their roles. It is evident that intellectual disability nurses must be responsive to the changing landscape of service provision and also the requirements for contemporary new roles to meet the changing needs of people with intellectual disabilities.

Use of a pharmacy-based GP video consultation service: a mixed methods study.

BACKGROUND: Little is known about private general practice appointment services offered via video. This study aimed to explore which patients are using a video pharmacy-based general practitioner (GP) appointment service, including patterns of use, reasons for using the service, and satisfaction with the service. METHODS: Descriptive statistics and parametric and nonparametric tests were used to conduct a retrospective cross-sectional analysis of routinely collected data on consultations, and postconsultation questionnaires. Interviews were conducted with patients and GPs. RESULTS: A total of 7,928 consultations were included in the analysis. More than half of appointments were booked for the same day, with lunchtime appointments being popular. The most common health condition was respiratory conditions, and 9% of consultations were used by patients using the service more than once. At least one prescription was issued in over half of all consultations. Overall, satisfactions of consultations were high. CONCLUSIONS: The characteristics of those patients using the video consultation service match data on who uses online services in general practice. This study shows that some patients are willing to pay to use this private service because they feel it is more convenient, NHS services do not have capacity to see them at the time they need, or they do not have access to regular GP services.

Over recent years, improvements in technology have made video and telephone general practitioner (GP) appointments more popular, and the Covid-19 pandemic has increased the need for these. There are lots of companies offering private GP appointments over video, but we do not yet know much about these, or why some people choose them over traditional GP appointments. This research aimed to find out which groups of people chose to use one private service that offers GP appointments over video in pharmacies, and why they chose to use it. The service has medical equipment (such as blood pressure monitor and camera) that can be used during the video GP appointment. Information was collected about 7,928 appointments in the time the study looked at, and 10 GPs that provide appointments, and 9 patients that used the service were interviewed to find out how they felt about it. Patients using this service were satisfied with their appointment, and were satisfied with the Doctor they saw. Reasons they chose to use the service included that they could be seen quicker than their normal GP, or at a time that was more convenient to them.

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

BACKGROUND: The use of web-based services within primary care (PC) in the National Health Service in England is increasing, with medically underserved populations being less likely to engage with web-based services than other patient groups. Digital facilitation-referring to a range of processes, procedures, and personnel that seek to support patients in the uptake and use of web-based services-may be a way of addressing these challenges. However, the models and impact of digital facilitation currently in use are unclear. OBJECTIVE: This study aimed to identify, characterize, and differentiate between different approaches to digital facilitation in PC; establish what is known about the effectiveness of different approaches; and understand the enablers of digital facilitation. METHODS: Adopting scoping review methodology, we searched academic databases (PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library) and gray literature published between 2015 and 2020. We conducted snowball searches of reference lists of included articles and articles identified during screening as relevant to digital facilitation, but which did not meet the inclusion criteria because of article type restrictions. Titles and abstracts were independently screened by 2 reviewers. Data from eligible studies were analyzed using a narrative synthesis approach. RESULTS: A total of 85 publications were included. Most (71/85, 84%) were concerned with digital facilitation approaches targeted at patients (promotion of services, training patients to improve their technical skills, or other guidance and support). Further identified approaches targeted PC staff to help patients (eg, improving staff knowledge of web-based services and enhancing their technical or communication skills). Qualitative evidence suggests that some digital facilitation may be effective in promoting the uptake and use of web-based services by patients (eg, recommendation of web-based services by practice staff and coaching). We found little evidence that providing patients with initial assistance in registering for or accessing web-based services leads to increased long-term use. Few studies have addressed the effects of digital facilitation on health care inequalities. Those that addressed this suggested that providing technical training for patients could be effective, at least in part, in reducing inequalities, although not entirely. Factors affecting the success of digital facilitation include perceptions of the usefulness of the web-based service, trust in the service, patients' trust in providers, the capacity of PC staff, guidelines or regulations supporting facilitation efforts, and staff buy-in and motivation. CONCLUSIONS: Digital facilitation has the potential to increase the uptake and use of web-based services by PC patients. Understanding the approaches that are most effective and cost-effective, for whom, and under what circumstances requires further research, including rigorous evaluations of longer-term impacts. As efforts continue to increase the use of web-based services in PC in England and elsewhere, we offer an early typology to inform conceptual development and evaluations. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020189019; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019.