Current experience and future potential of facilitating access to digital NHS primary care services in England: the Di-Facto mixed-methods study
Authors: Abel Gary , Atherton Helen , Sussex Jon , Akter Nurunnahar , Aminu Abodunrin Q , Bak Wiktoria , Bryce Carol , Clark Christopher E , Cockcroft Emma , Evans Hamish , Gkousis Evangelos , Jenkins Georgia , Jenkinson Caroline , Khan Nada , Lambert Jeffrey , Leach Brandi , Marriott Christine , Newbould Jennifer , Parkinson Sarah , Parsons Jo , Pitchforth Emma , Sheard Laura , Stockwell Stephanie , Thomas Chloe , Treadgold Bethan , Winder Rachel , Campbell John L 
Published: September 2024

Background
Current National Health Service policy in England encourages enhanced digital access in primary care service provision. In this study, we investigate ‘digital facilitation’ – that range of processes, procedures and personnel which seeks to support National Health Service primary care patients in their uptake and use of online services.

Objectives

Identify, characterise and explore the potential benefits and challenges associated with different models of digital facilitation currently in use in general practice which are aimed at improving patient access to online services in general practice in England.
Use the resulting intelligence to design a framework for future evaluations of the effectiveness and cost effectiveness of such interventions.
Explore how patients with mental health conditions experience digital facilitation and gauge their need for this support.

Design
Observational mixed-methods study (literature review, surveys, ethnographic observation and interviews); formal synthesis of findings.

Setting
General practice in four regions of England.

Participants

Practice survey: 156 staff.
Patient survey: 3051 patients.
Mental health survey: 756 patients.
General practitioner patient survey: 3 million responders.
Ethnographic case-studies: 8 practices; interviews with 36 staff, 33 patients and 10 patients with a mental health condition.
Stakeholder interviews: 19 participants.

Intervention
Digital facilitation as undertaken in general practice.

Main outcome measures
Patient and practice staff reported use of, and views of, digital facilitation.

Data sources
Surveys, qualitative research; national General Practitioner Patient Survey (2019–22).

Review methods
Scoping-review methodology applied to academic and grey literature published 2015–20.

Results
While we did find examples of digital facilitation in routine practice, these often involved using passive or reactive modes of support. The context of COVID, and the necessary acceleration (at that time) of the move to a digital-first model of primary care, shaped the way digital facilitation was delivered. There was lack of clarity over where the responsibility for facilitation efforts lay; it was viewed as the responsibility of ‘others’. Patients living with mental health conditions had similar needs and experiences regarding digital facilitation to other patients.

Limitations
The context of the COVID pandemic placed limitations on the project. Fewer practices responded to the practice survey than anticipated; reconfiguration of general practices to support COVID measures was a key consideration during non-participant observation with social distancing and other measures still in place during fieldwork.

Conclusions
Digital facilitation, while not a widely recognised concept, is important in supporting the move to a National Health Service with enhanced digital opportunities and enhanced digital access. General practice staff are allocating resources to provide such efforts in general practices in England. The establishment of clear lines of responsibility, the development of digital tools and platforms that work for patients and practice staff, and investment in staff time and training are needed if digital facilitation is to support the intended digital revolution.

Future work
We did not find one single dominant or preferred model of digital facilitation which might reasonably be considered to form the basis of an intervention to be tested. Rather, there is a need to co-develop such an intervention with patients, general practice staff and relevant policy experts. We outline a framework for a future evaluation of such an intervention.

Study registration
This study is registered as ResearchRegistry6523 (www.researchregistry.com/browse-the-registry#home/?view_2_search=Di-Facto&view_2_page=1) and PROSPERO CRD42020189019 (www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019).

Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128268) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 32. See the NIHR Funding and Awards website for further award information.