Greenhalgh Trisha, Alvarez Nishio Anica, Clarke Aileen, Byng Richard, Dakin Francesca, Faulkner Stuart, Hanson Isabel, Hemmings Nina, Hughes Gemma, Husain Laiba, Kalin Asli, Ladds Emma, MacIver Ellen, Moore Lucy, O'Rourke Sarah, Payne Rebecca, Pring Tabitha, Rosen Rebecca, Rybczynska-Bunt Sarah, Shaw Sara E, Swann Nadia, Wieringa Sietse, Wherton Joseph
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
Lay Chair of RBD2 Advisory Group, London, UK.
Health Soc Care Deliv Res. 2025 Sep;13(31):1-49. doi: 10.3310/QQTT4411.
Remote services (in which the patient and staff member are not physically colocated) and digital services (in which a patient encounter is digitally mediated in some way) were introduced extensively when the COVID-19 pandemic began in 2020. We undertook a longitudinal qualitative study of the introduction, embedding, evolution and abandonment of remote and digital innovations in United Kingdom general practice. This synoptic paper summarises study design, methods, key findings, outputs and impacts to date.
From September 2021 to December 2023, we collected > 500 hours of ethnographic observation from a diverse sample of 12 general practices. Other data sources included over 200 interviews (with practice staff, patients and wider stakeholders), 4 multi-stakeholder workshops (184 participants), grey literature (e.g. Care Quality Commission reports) and safety incident reports. Patient involvement included digitally excluded individuals from disadvantaged backgrounds (e.g. homeless, complex needs). Data were de-identified, uploaded to NVivo (QSR International, Warrington, UK), coded thematically and analysed using various theoretical lenses. Despite an adverse context for general practice including austerity, workforce shortages, rising demand, rising workload and procurement challenges, all 12 participating practices adjusted to some extent to a 'new normal' of hybrid (combined traditional and remote/digital) provision following the external shock of the pandemic. By late 2023, practices showed wide variation in digital maturity from a 'trailblazer' practice which used digital technologies extensively and creatively to 'strategically traditional' practices offering mainly in-person services to deprived and vulnerable populations. We explained practices' varied fortunes using diffusion of innovations theory, highlighting the extensive work needed to embed and routinise technologies and processes. Digitally enabled patients often, but not always, found remote and digital services convenient and navigable, but vulnerable groups experienced exclusion. We explored these inequities through the lenses of digital candidacy, fractured reflexivity and intersectionality. For staff, remote and digital tasks and processes were often complex, labour-intensive, stressful and dependent on positive interpersonal relations - findings that resonated with theories of technostress, suffering and relational co-ordination. Our initial plan for workshop-based co-design of access pathways with patients was unsuccessful due to dynamic complexities; shifting to a more bespoke and agile design process generated helpful resources for patients and staff.
This study has confirmed previous findings from sociotechnical research showing that new technologies are never 'plug and play' and that appropriate solutions vary with context. Much variation in digital provision in United Kingdom general practice reflects different practice priorities and population needs. However, some practices' low digital maturity may indicate a need for additional resources, organisational support and strengthening of absorptive capacity. Negative impacts of digitalisation are common but not always inevitable; an 'inefficient' digital pathway may become more efficient over time as people adapt; and digitalisation does not affect all work processes equally (back-office tasks may be easier to routinise than clinical judgements). We have developed novel ways of involving patients from vulnerable and excluded groups, and have extended the evidence base on codesign for the busy and dynamic setting of general practice. Findings are being taken forward by national, locality-based and practice-level decision-makers; national regulators (e.g. in relation to safety); and educational providers for undergraduate, postgraduate and support staff (via a new set of competencies).
Ongoing and planned work to maximise impact from this study includes using our competency framework to inform training standards, pursuing our insights on quality and safety with policy-makers, a cross-country publication for policy-makers with examples from colleagues in other countries, resources to convey key messages to different audiences, and continuing speaking engagements for academic, policy and lay audiences.
The sampling of practices was limited to Great Britain. Patient interviews were relatively sparse. While the study generated rich qualitative data which was useful in its own right, a larger sample of practices with a quantitative component could support formal hypothesis-testing, and a health economics component could allow firmer statements about efficiency.
This synopsis 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.
2020年新冠疫情爆发后，远程服务（患者和工作人员不在同一物理位置）和数字服务（患者就诊以某种方式通过数字手段进行介导）被广泛采用。我们对英国全科医疗中远程和数字创新的引入、融入、演变及废弃情况进行了一项纵向定性研究。本综述性论文总结了研究设计、方法、主要发现、成果及迄今为止的影响。
2021年9月至2023年12月，我们从12家全科医疗机构的不同样本中收集了超过500小时的人种志观察资料。其他数据来源包括200多次访谈（与医疗机构工作人员、患者及更广泛的利益相关者）、4次多利益相关者研讨会（184名参与者）、灰色文献（如护理质量委员会报告）以及安全事件报告。患者参与包括来自弱势背景（如无家可归、需求复杂）的数字排斥个体。数据经过去识别处理后上传至NVivo（QSR国际公司，英国沃灵顿），进行主题编码，并使用各种理论视角进行分析。尽管全科医疗面临不利环境，包括财政紧缩、劳动力短缺、需求上升、工作量增加和采购挑战，但在疫情的外部冲击后，所有12家参与研究的医疗机构都在一定程度上适应了混合（传统与远程/数字相结合）服务的“新常态”。到2023年底，各医疗机构在数字成熟度方面差异很大，从广泛且创造性地使用数字技术的“先驱”机构到主要为贫困和弱势群体提供面对面服务的“战略传统”机构。我们运用创新扩散理论解释了各医疗机构不同的发展情况，强调了嵌入和常规化技术及流程所需的大量工作。使用数字技术就诊的患者通常（但并非总是）觉得远程和数字服务方便且易于操作，但弱势群体却遭遇排斥。我们通过数字适格性、断裂反思性和交叉性等视角探讨了这些不平等现象。对于工作人员而言，远程和数字任务及流程往往复杂、劳动强度大、压力大且依赖积极的人际关系——这些发现与技术压力、痛苦和关系协调理论相呼应。我们最初基于研讨会与患者共同设计接入途径的计划因动态复杂性而未成功；转向更定制化和灵活的设计过程为患者和工作人员生成了有用的资源。
本研究证实了社会技术研究先前的发现，即新技术绝非“即插即用”，且合适的解决方案因背景而异。英国全科医疗中数字服务的很大差异反映了不同的医疗机构优先事项和人群需求。然而，一些医疗机构较低的数据成熟度可能表明需要额外资源、组织支持和吸收能力的加强。数字化的负面影响很常见，但并非总是不可避免；随着人们的适应，一条“低效” 的数字途径可能会随着时间推移变得更高效；而且数字化对所有工作流程的影响并不相同（后台任务可能比临床判断更容易常规化）。我们开发了让弱势群体和被排斥群体患者参与的新方法，并扩展了在忙碌且动态的全科医疗环境中共同设计的证据基础。国家、地方和医疗机构层面的决策者、国家监管机构（如在安全方面）以及本科、研究生和辅助人员的教育提供者（通过一套新的能力标准）正在推进这些发现。
为使本研究的影响最大化，正在进行和计划开展的工作包括利用我们的能力框架为培训标准提供信息，与政策制定者探讨我们对质量和安全的见解，为政策制定者撰写一份包含其他国家同事案例的跨国出版物，提供向不同受众传达关键信息的资源，以及继续面向学术、政策和普通受众进行演讲。
医疗机构的抽样仅限于英国。患者访谈相对较少。虽然该研究生成了丰富的定性数据，其本身很有用，但更大的包含定量部分的医疗机构样本可以支持正式的假设检验，并且增加健康经济学部分可以更有力地说明效率问题。
本综述展示了由英国国家卫生与保健研究所（NIHR）卫生与社会保健交付研究项目资助的独立研究，资助编号为NIHR132807。
