We recently caught up with Helen Atherton, professor in primary care research at the University of Southampton, to talk about her research findings and insights into digital in primary care.
Helen first shared with us a brief introduction to her role and how she first got into research in the primary care field, sharing that her background is “actually a mixture of anthropology and public health”. She ended up working in primary care research “almost by accident” after getting a job as a research assistant in a general practice grouping at a university.
“I absolutely loved it,” Helen said. “When it came time to decide what I was going to do for my PhD, there was some budding work at the time around the use of email for consultations, so I ended up focusing on that. Everything since has come from there.”
Previous projects
Moving on to talk about previous projects, Helen told us about her work prior to the pandemic, which included a large study looking at alternatives to face-to-face consultations in general practice, with findings being used by NHS England to provide guidance around online consultations.
“Just before the pandemic hit, I was working on a project around online booking services and how patients interact with those, who uses them and who doesn’t; and also telephone-first methods of access. At the time they were either emerging or not used very much, but the pandemic changed everything quite quickly.”
Since the pandemic, Helen has been working on digital facilitation and how patients can be helped and supported to use the digital services available in general practice. She has recently finished a large project with the University of Exeter exploring how this currently works and looking at the kinds of support patients are getting and whether it is helping them to use services. She acknowledged that one of the biggest challenges around the increased digital offering is that there are people it doesn’t reach and people who struggle to use it. “It’s been shown in in evidence that there’s still a lot of work to be done to make it something that everyone can benefit from,” she stated.
Helen also highlighted some research she is currently working on with colleagues from the Norwegian Centre for e-health research in Norway, on the use of online consultations. “It’s been really interesting to see how these things are done in another country. I think in the UK, the commercial sector is much more influential, whereas in Norway their online services are run mostly through the government, so a bit more like the NHS app set up.”
Findings from research on digital in primary care
We asked Helen if she could share some of the key findings from her research on video consultations in primary care, and she highlighted results from a feasibility study of video consultations in Scotland where they identified a greater need for remote communication.
“We had to pay for the practices to have better broadband and tablet computers, which was really interesting. It’s still a problem across NHS primary care, that the infrastructure just doesn’t support a lot of these things very well,” she noted. “We found that when we looked at the quality of the consultations, comparing face-to-face with telephone and video, there are fewer differences between telephone and video. This is not surprising, but the visual cues that video provides are really the only thing that it offers over and above the telephone, which I think probably explains the low levels of use.”
Helen added that from her time spent in a discussion group with researchers from across Western Europe, and with a PhD student studying video consultations in Denmark, she had realised that levels of uptake were low across Europe.
“In the UK, video consultations only make up about two percent of consultations in primary care,” she said. “For some reason it’s just not getting that uptake. It seems to be that wherever you look at it, it always comes down to the same thing, like infrastructure and whether it’s just more convenient to pick up the phone. In the research that we did in Scotland, we saw that the quality of video consultations was slightly lower in terms of factors such as empathy, so there was something lost in not being in the same room. It wasn’t a huge difference, but it was there. There just seem to be lots of little factors preventing video from fully take off as a consultation option.”
Looking at where digital options can offer the most value in primary care, Helen said: “What’s come out in all of the research that I’ve done is the convenience factor. I think convenience, and the idea that patients might want to do something that is convenient, often gets underplayed. There are also particular patient groups that seem to really benefit from remote methods of consultation, like people with agoraphobia. Also, I’d say that some of the current access systems that we have are not well aligned with people who work – but that’s not really the fault of the communication mode, that’s just the way things are set up.”
Barriers and missed opportunities in digital primary care
In terms of missed or unfulfilled opportunities for digital in general practice, Helen noted that often the technologies that are available are not necessarily made the most of, usually due to people struggling to use them, or to a lack of infrastructure.
“I would say that the reality is much messier than the rhetoric. One thing shown in a couple of studies which will hopefully be published soon is that people with long-term conditions tend to be much better at using online technology for things like e-prescriptions, online booking or managing their healthcare; presumably because they have to do it more. But a lot of people are only going to go to their GP maybe a couple of times per year, and they have to get their head around using something that could be quite complex. So I think we could do more to support general practice, to make these things a bit simpler, a bit clearer, and get more people using them.”
When it comes to barriers to the implementation of digital health interventions in primary care, Helen noted the pressures that staff in general practice are under, meaning they “don’t necessarily have the headspace to sort these things out”.
“Recently we did field work in general practice, to see how they’re helping people to use digital services, and it was very reactive. For example, a patient comes in, they need help with the NHS app, and they get that help, then off they go. Doing that over and over again with individual patients is actually creating more work, and stopping staff from having the time to explore options to increase understanding on a wider level. It’s a big challenge; I’m not sure how you solve it. I know there are various funding streams and incentives to the GP contracts, but it just feels a little bit like people are kind of chasing their tails.”
Helen also talked about communication with patients needing to be better, referring to things like answering machine messages as “clunky”.
“The fact that the NHS app sits outside of general practice and is run outside of general practice is confusing for patients, I think,” she reflected. “General practice can’t really help people to use it, because they don’t have any control over it, so that doesn’t help. It comes down to logistical challenges.”
Future directions for research on digital communication in general practice
Moving on to areas that she would maybe like to explore in the future, Helen discussed the opportunity to work on developing a simple intervention to help general practices to support patients.
“I would love to do more work on written consultation. When I started my research, I was looking at emails between doctors and patients, and there were some real positives from that; it wasn’t abused in the way that people might imagine. I think that there could be a role for a written type of consultation in the future, via email.
“The other thing that I think is really important is the total triage model that is currently being pushed by NHS England, which I think is at odds with all the evidence that we have about how different groups struggle with online access and so on. I think there definitely needs to be a look at these different kinds of online tools to see what impact they’re having on particular patient groups and also on workload.”
The increased use of digital tools and the increasing levels of support needed have had the “biggest impact has been on reception staff,” Helen added, “because they’re helping patients with digital and they’re also doing a lot more triage on the phone. I wonder if we might see some kind of revolution around how that front desk is managed; maybe that’s where things like AI will come in.”
We’d like to thank Helen for her time in sharing insights from her research with us.
