Title: Remote by Default 2: the 'new normal'?
Funder: Department of Health and Social Care

Abstract: AIM_x000D_ To inform high-quality, safe and equitable care in UK general practice in the context of policies which require phone, video or e-consultation by default._x000D_ _x000D_ BACKGROUND_x000D_ When COVID-19 struck, general practice shifted to predominantly phone, video or e-consultations instead of face-to-face. Remote had benefits (e.g. reducing spread of COVID-19), but also downsides (technical glitches; inequalities of access; missed diagnoses; reduced continuity of care; and patients simply not seeking care at all). Despite this, Matt Hancock declared on 30th July 2020 that remote-by-default is here to stay._x000D_ _x000D_ RESEARCH QUESTION_x000D_ To what extent is remote-by-default, introduced for infection control during the pandemic, fit for purpose for the long term – and how can we make remote care better and safer?_x000D_ _x000D_ DESIGN AND METHODS_x000D_ Mixed-method case study with co-design workshops and cross-sector stakeholder events._x000D_ _x000D_ OBJECTIVES AND METHODS_x000D_ _x000D_ 1. GP PRACTICES_x000D_ We will support 11 GP practices to develop effective remote services and alternatives where needed. We’ll help them collect data and use their findings to inform improvement efforts._x000D_ _x000D_ 2. PATIENTS_x000D_ We will interview 40 patients selected for diversity (age, ethnicity, locality, socio-economic status, condition[s], digital literacy), and hold two workshops (one remotely and one in person, Covid allowing) where patients help co-design ways to combine remote and face-to-face models._x000D_ _x000D_ 3. WIDER SYSTEM_x000D_ We will engage stakeholders – including policymakers, professional bodies, industry, civil society and patient groups – in ongoing dialogue about how to deliver and support a more equitable, less risky remote-by-default service. We’ll interview them and hold cross-sector stakeholder events (big Zoom meetings), working both before and after the events to build relationships and action ideas._x000D_ _x000D_ KEY THEMES TO STUDY_x000D_ _x000D_ 1. QUALITY AND SAFETY OF CARE, illustrated by 4 kinds of consultation: _x000D_ a. long-term conditions e.g. diabetes; _x000D_ b. continuity of care (being able to see one’s own doctor or nurse);_x000D_ c. early detection of cancer (e.g. how easy it is to get seen for a new breast lump);_x000D_ d. multiple complex conditions (including patients in care homes);_x000D_ _x000D_ 2. INEQUALITIES OF ACCESS relating to (e.g.) health or digital literacy, language barriers, financial hardship, or nature of disability or illness; _x000D_ _x000D_ 3. WORKFORCE, including staff well-being, training and supervision;_x000D_ _x000D_ 4. INFRASTRUCTURE, including technical (hard/software, interoperability) and regulatory (e.g. information governance, quality inspections) challenges._x000D_ _x000D_ PATIENT AND PUBLIC INVOLVEMENT_x000D_ We have an established external advisory group with extensive lay representation including a lay chair (AAN, co-applicant). We have strong links to local PPI groups in our study sites, and will establish a PPI virtual group with buddying of others not fully online. Patients and lay people have been formatively and iteratively involved throughout the current project; their input has been crucial to shaping this bid (especially the kinds of remote consultations they’re most concerned about). They will continue to be actively involved in all aspects of the study._x000D_ _x000D_ DELIVERABLES_x000D_ Summary of range of patient/carer experience of remote, 4 digital inclusion workshops, support for change in 10 GP practices, cross-case learning, 4 cross-sector stakeholder events with follow-on support for policy action, academic papers, policy briefings, lay summaries & resources.

Lay abstract: BACKGROUND_x000D_ The remote-by-default policy in UK general practice, introduced for infection control during the acute phase of the pandemic, seems likely to be continued long term. There are unanswered questions about how to optimise this service model._x000D_ _x000D_ AIM_x000D_ To inform a more fit-for-purpose remote-by-default model in general practice which takes account of a) quality and safety of care, b) equity and inclusivity, c) staff wellbeing and training, and d) the wider technical and regulatory infrastructure._x000D_ _x000D_ RESEARCH QUESTIONS_x000D_ 1. How can we ensure that the remote-by-default model supports high-quality, safe care to all patients (including those at risk of digital exclusion)?_x000D_ 2. How can we balance a remote-by-default model with the provision of traditional face-to-face consultations where appropriate?_x000D_ 3. How can we meet the wellbeing and training needs of general practice staff as remote-by-default becomes business as usual?_x000D_ 4. What are the infrastructural challenges of remote-by-default and how can they be overcome?_x000D_ _x000D_ STUDY DESIGN _x000D_ Mixed-method, multi-site case study with co-design workshops and cross-sector stakeholder events._x000D_ _x000D_ OBJECTIVES AND BRIEF METHODS_x000D_ _x000D_ 1. PRACTICE LEVEL_x000D_ Objective: Follow a maximum-variety sample of 11 GP practices for 2 years as they seek to introduce, improve and sustain remote-by-default consultations, supporting them in developing effective remote services and equitable alternatives where needed. _x000D_ Methods: Build mixed-methods longitudinal case studies via staff interviews, document analysis, ethnography (adapted to virtual if necessary). Support practices through action research and 2 digital inclusion co-design workshops._x000D_ _x000D_ 2. PATIENT LEVEL_x000D_ Objective: Capture the patient experience of remote-by-default consultations and ensure this perspective is incorporated in practice- and system-level efforts to improve and augment remote-by-default services._x000D_ Methods: 40 interviews and 2 digital inclusion co-design workshops with patients and carers._x000D_ _x000D_ 3. SYSTEM LEVEL_x000D_ Objective: Engage stakeholders – including policymakers, professional bodies, industry, civil society and patient groups – in an ongoing dialogue about how to deliver and support a more equitable, less risky remote-by-default service._x000D_ Methods: 20 elite interviews plus 4 stakeholder events (see below)_x000D_ _x000D_ PATIENT AND PUBLIC INVOLVEMENT (PPI)_x000D_ • External advisory group with independent lay chair and wide range of lay members bringing cross-sector experience from (e.g.) industry, 3rd sector, arts, policy_x000D_ • Patient/lay input to study design_x000D_ • PPI virtual group with buddying of others not fully online_x000D_ • Innovative approaches to involvement described in main bid _x000D_ _x000D_ KEY DELIVERABLES_x000D_ • 4 digital inclusion co-design workshops (2 for patients and carers, 2 for GP practice staff)_x000D_ • Report on diversity of patient experience of remote-by-default, plus digital inclusion personas to feed into other design activities_x000D_ • 2 years of action research with 10 GP practices to help deliver their priority goals_x000D_ • Written case studies and cross-case analysis of practices’ experiences_x000D_ • 4 large-scale cross-sector stakeholder events with preparatory and follow-up activities with policy, NHS, industry and patient groups_x000D_ • Ongoing relationships and implementation action as invited with national-level stakeholders _x000D_ • Academic papers, policy briefings_x000D_ • Lay summaries and resources

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE