Remote by default primary care [COVID-19]

• Research type

  Research Study

• Full title

  Scaling up Remote-by-Default Models of Care to Help Reduce the Spread of COVID-19

• IRAS ID

  283196

• Contact name

  Trish Greenhalgh

• Contact email

  trish.greenhalgh@phc.ox.ac.uk

• Sponsor organisation

  University of Oxford

• Duration of Study in the UK

  1 years, 11 months, 30 days

• Research summary

  Research Summary
  With a view to containing novel coronavirus (COVID-19), healthcare organisations in the UK (and beyond) are rapidly introducing new service models which avoid direct clinician-patient contact. This shift from in-person to remote consulting is the fastest and most extensive scale-up of a radical service innovation since the NHS was established in 1948. The change is logistical and cultural as well as technical. Clinicians are faced with a triple challenge: a new disease (uncertain, serious and highly contagious) and a new way of interacting with patients (e.g. video consultations with individuals and groups; via designated physical ’hot hub’ sites for Covid-suspected patients) and major changes to team interactions, workflows and clinical pathways. In short, ’remote-by-default’ is a paradigm case of a disruptive innovation. It is complex, uncertain, challenging and risky. Furthermore, it is abruptly redefining what it means to be a patient, a doctor/nurse, a healthcare assistant and so on, and what it is to provide excellent healthcare. \nWe’d like to apply our expertise to the new challenges thrown up by the pandemic – specifically the question of how to achieve rapid spread and scale up of hot hubs, and – longer term - new remote-by-default models in primary care. To do so, our study will consist of two components:\na)\tA rapid evaluation phase that maps different types of hot hubs, delivering rapid learning and feedback to sites and policymakers about what works well and what does not. \nb)\tLongitudinal comparative case studies of primary care sites across England and Scotland, generating rich in-depth narratives of scale-up of remote-by-default models in primary care and the impacts on staff and patients. \n\n

  Summary of Results
  Funder: UK Research and Innovation, Economic and Social Research Council and the National Institute for Health Research Grant reference number: ES/V010069/1

  Sponsor: University of Oxford, Clinical Trials and Research Governance., Joint Research Office, 1st Floor Boundary Brook House, Churchill Drive, Headington, OX3 7GB

  Aims of the research
  Because COVID-19 is so contagious, the way the NHS works since the pandemic began has changed dramatically. For the first time since 1948, you can’t walk into a GP surgery and ask to be seen. You must apply online, phone the surgery, or contact NHS111. You may then get a call-back (phone or video) from a clinician, or a face-to-face appointment. This is called ‘Remote by Default- that is, the main way to get to see your GP and other primary care staff is now remote, not in-person.

  Researchers at Oxford University, Plymouth University and the Nuffield Trust are an interdisciplinary team specialising in the study of complex, technology-supported change in health and care settings.

  Using a variety of methods, we aimed to do three things:
  1) Develop tools to help clinicians assess people effectively by phone or video.
  2) Support the change from face-to-face to remote consultations through ‘action research’ –that is, working with GP teams to collect relevant data, analyse it together and support its rapid use.
  3) Working with other clinicians and researchers to improve the ability of the NHS to strengthen the supporting infrastructure for digital innovation in the NHS such as ways of working, staff skills and information technology systems.

  Background to the research
  The shift from in-person to remote-by-default consulting is the fastest and most extensive scale-up of a radical service innovation since the NHS was established in 1948. Clinicians are faced with several novel challenges at the same time: a new disease (uncertain, serious, and contagious), a new way of interacting with patients (phone and video) and major changes to workflows and clinical pathways. Lives will depend on getting the right patients to hospital at the right time to ensure benefit from critical care without overwhelming the hospital with referrals.

  This requires accurate identification of patients for referral and monitoring of those with moderate disease. Success is not just about introducing or using new technologies. It is also about ensuring clinical safety, how we can make technologies work well, and whether the way the NHS is organised and operates can accommodate them quickly and widely. We know from research on health systems that introducing new technologies into health systems (for example video consultations) is complex, uncertain, challenging, and risky.
  To understand and answer this gap in knowledge requires several different approaches and academic skills. It involves clinical questions such as, how we should assess and manage COVID-19? There are operational questions such as, how can we overcome the barriers to change that involve how people, technology and the workplace interact? There are also policy-related questions too such as, how can policy and regulatory bodies support innovation?

  Design and methods used

  Research questions

  1.How can technology support assessment and monitoring of patients at a distance?

  2.How can we achieve rapid replication of remote-by-default models of primary care across different locations and the required changes to NHS infrastructure to support that?

  3.What insights can we gather from this time of crisis that will help build a more resilient NHS?

  Methods

  1.TOOLS:
  • Interview front-line GPs, Nurse Practitioners and other staff assessing patients with possible COVID-19 symptoms, and patients/carers who have experienced key symptoms of breathlessness/fatigue during the pandemic period.
  • Produce and test questions for GPs to ask patients about their breathlessness.
  • Develop, test and validate a COVID-19-specific early warning score that uses items that can be assessed remotely by staff.

  2.IMPLEMENTATION AND SCALE-UP OF REMOTE BY DEFAULT:
  • Interview GPs, nurses and other staff, across 4 different and contrasting sites in the UK in order to support the change process to remote by default models of primary care at these sites (i.e., ‘action research’).

  3.WORKSHOPS AND SCENARIO-TESTING:
  • Involving policymakers, regulators, professional bodies, industry, patients/citizens, hold workshops to identify ways to strengthen NHS infrastructure to enable rapid change to remote by default models of primary care and generate policy recommendations.

  Patient and public involvement
  We formed a ‘Remote By Default Patient, Public Involvement and Engagement Group’. It includes a range of stakeholders including service users and representatives with lived experience of COVID-19 and remote care and reflect the diversity of experience in the community. The advisory group reviewed and improved the original study proposal. They provided a quarterly review of the study progress, addressed ethical considerations, highlighted ways to improve the study as it progresses and were involved in workshops and scenario-testing, and preparing policy briefs.

  Main findings and impact

  DISCOVERY 1: Tools and techniques for clinical assessment of acute COVID-19
  • A set of questions and a predictive tool have been built into electronic records and designed to distinguish people with suspected COVID-19 who need to go to hospital from those who can safely be monitored at home.
  • The final Remote COVID-19 Assessment in Primary Care (RECAP) score divides people into 'green' (stay at home, self-monitor), amber (professional monitoring e.g., via virtual wards with home oximetry), or red (assess in person promptly).
  • We understand that the RECAP score is now embedded in ambulance and out of hours systems for assessment of patients with COVID-19. https://eur03.safelinks.protection.outlook.com/?url=http%3A%2F%2Furl6570.hra.nhs.uk%2Fls%2Fclick%3Fupn%3DXv3JSvJ-2B3M71ppf7N9agbX34k-2B38iicKxp7z4CdBgCF6fzLjR0FttDij3mpsRzdhhvImIedl3frH1FP3U0uX9zk1xO6PPVLHZnPHBmiZYMSAmMMvk3ghlztlIUX7sx3Q_frz_E1aO2-2BZlVOSJJV-2FajQqskegTd6IRomHYTi-2Fbt8SH3YJZwYkeuvhrFlXeeGeh8usOsg1QSwhA82EHGWJ4j6Vmmm8ryOqXJcgEy5o-2FOiwwNCU9ULm5wA2-2Bf9GnHDnPCuH8yi3pHL3PiXbsCYUx4gxobg-2B5GokPD9EWMmHKjcm1vgtZlBCa3e6hcARBRaI6tk0K9vqCH8RdWhUKDwqBy1od7Q-3D-3D&data=04%7C01%7Capprovals%40hra.nhs.uk%7C9afe623fcded4af3c59c08da119817c4%7C8e1f0acad87d4f20939e36243d574267%7C0%7C0%7C637841642477102696%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=SdWtGq3A87JYqX1Zu2StiC1gk8uHSqF5kJdHJ%2BMCF1M%3D&reserved=0

  DISCOVERY 2: Qualitative insights and policy change in Long COVID-19
  • The largest qualitative study to date (over 100 people) of the lived experience of Long COVID-19 (i.e., in people that have symptoms lasting weeks or months after the infection has gone).
  • Their stories, along with other research by other teams, informed academic papers and also key policy changes for Long COVID-19 such as NICE guidelines, a House of Lords report, new NHS clinics and further research funding.

  DISCOVERY 3: Studies of rapid introduction of remote by default services
  • We developed and tested a Planning and Evaluating Remote Consultation Services (PERCS) framework. It contains the following key domains that can help organisations better understand the challenges of establishing and running remote consultation services;
  1.The system context (e.g. regulation and infrastructure), 2. The organization (e.g. workload and staffing), 3.Technologies (e.g. familiarity and functionality), 4.Staff (e.g. values and capabilities), 5.The reason for consulting (e.g. risk and urgency), 6.The patient (general health and attitudes and preferences), 7.The home and family (e.g., digital setup, capability and safeguarding) https://eur03.safelinks.protection.outlook.com/?url=http%3A%2F%2Furl6570.hra.nhs.uk%2Fls%2Fclick%3Fupn%3DXv3JSvJ-2B3M71ppf7N9agbTz8cxsQF9Zcn5jbmwy3NZeOuX87ZC2uz5AC-2FyZmBL8mLrDuDdQzVcP4TrXR-2B3zbxk03I5-2B64n-2FqFk1SZfG5Kl0-3DxQ7g_E1aO2-2BZlVOSJJV-2FajQqskegTd6IRomHYTi-2Fbt8SH3YJZwYkeuvhrFlXeeGeh8usOO0fcUwFuFpgbq-2Bltp-2B6VgLhez-2BKhrVk21Oz2ekVBaoBTr3n78FIDTWjRE1E4Y09uZzmosSdGgmvC6o2FpYanHaYvdA6NROVV5XvtLobLUrPwgrejtTe67eLC-2F0axR-2Bvsuk3ltLtQhColHRCXb-2Bedbg-3D-3D&data=04%7C01%7Capprovals%40hra.nhs.uk%7C9afe623fcded4af3c59c08da119817c4%7C8e1f0acad87d4f20939e36243d574267%7C0%7C0%7C637841642477102696%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=%2Bws5wZBev9N8WRPa4DhKIgUCb22Gl8v6%2FIS4TpujGnw%3D&reserved=0
  • The PERCS framework is used by Scottish, Welsh and English digital transformation teams to inform their work supporting GP practices to provide remote consultations and has also informed further work on decision making about remote consulting in secondary care.
  • We produced policy briefings (published by the Nuffield Trust) which were widely distributed to policy groups in the UK.
  • NHS England commissioned us to co-design patient advice leaflets, web resources and a video on how to access and use digital services.
  Details of further research planned
  • This work has led directly to further funding from the National institute for Health Research for a 2.5-year study called, 'Remote by Default 2: The new Normal?' (Grant; HS&DR NIHR132807). This new study will increase the number of sites involved up to 11 GP practices across the UK – that cover a broader mix of rural, urban, low- and high-income locations and those with different levels of digital experience. It aims to further understand how and if the new model of Remote by Default is fit for purpose now and in the future.

  Where can I learn more about this study?
  ‘Remote by Default’ study
  Details of the study, research team, advisory group, outputs and links to publications can be found at;
  https://eur03.safelinks.protection.outlook.com/?url=http%3A%2F%2Furl6570.hra.nhs.uk%2Fls%2Fclick%3Fupn%3DXv3JSvJ-2B3M71ppf7N9agbeK0MNnzaJ-2FbRFJqXKdgaxH7R2XczOVHbI0OUKcmyZKzvnAYy2BSps-2FjJmUd0HY44gZfRDCrbwyTr5B9W0R2z7NI-2FtllkPJm7Sdcxq-2BQP6KV8UTCEZRU-2BUQOvZq6QBTLkrPZN4Fee2f3W77k2-2FZaSumi1eiRY5wFLhyaR-2BnlckQ4rlvIBtvmXA5lKs9fqzRPMQ-3D-3D8w_R_E1aO2-2BZlVOSJJV-2FajQqskegTd6IRomHYTi-2Fbt8SH3YJZwYkeuvhrFlXeeGeh8usOejtLnrLudHQh2z5IXFsi7eFAf4tRlEqpx-2FVfDSTBh44B2GBz6n95mOMeZPPdNJUKzikR1bUQuQxw8b-2BVPO-2FQxPT5K0dviph-2FtSKKXrdVMQzNbNSQjldDKs-2FUmUuSkKZ63FBqruhyY83r-2FdO3Jz3YHg-3D-3D&data=04%7C01%7Capprovals%40hra.nhs.uk%7C9afe623fcded4af3c59c08da119817c4%7C8e1f0acad87d4f20939e36243d574267%7C0%7C0%7C637841642477102696%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=eI3uRXxdHaOOTn%2FAuigqSUCqVlI%2BpHqNEwavEy0nAcA%3D&reserved=0

  Follow-on ‘Remote by Default 2: The new normal?’ study Remote by Default 2: the “new normal”?
  https://eur03.safelinks.protection.outlook.com/?url=http%3A%2F%2Furl6570.hra.nhs.uk%2Fls%2Fclick%3Fupn%3DXv3JSvJ-2B3M71ppf7N9agbeK0MNnzaJ-2FbRFJqXKdgaxH7R2XczOVHbI0OUKcmyZKzvnAYy2BSps-2FjJmUd0HY44gZfRDCrbwyTr5B9W0R2z7NI-2FtllkPJm7Sdcxq-2BQP6KV73cmVxin-2Bq-2F1ko-2FniyShIyip6xbIg-2BeXOdrCyzChfV7ArkJfLdtiyLZTUrMfncDb8u3y_E1aO2-2BZlVOSJJV-2FajQqskegTd6IRomHYTi-2Fbt8SH3YJZwYkeuvhrFlXeeGeh8usOMDsHkaTPNUKxxzRyBlUTSUYA-2BCAM6K0X9Puno-2FodlUgmTlQGSbpovLdw8V0lqfkiu-2FVcmtN3ddYf6nMNGkq5OgQ18vmXNeshlcJQG4ccJ72zSThLRxsW-2FuhPcgJW3pdDO-2Bd488pi3dA8eVEdLshSdA-3D-3D&data=04%7C01%7Capprovals%40hra.nhs.uk%7C9afe623fcded4af3c59c08da119817c4%7C8e1f0acad87d4f20939e36243d574267%7C0%7C0%7C637841642477102696%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=F0KcHlz0gR%2F2FsueB8db5X4voQ%2BYdSHLa2XFZSzs6SQ%3D&reserved=0

• REC name

  East Midlands - Leicester Central Research Ethics Committee

• REC reference

  20/EM/0128

• Date of REC Opinion

  4 May 2020

• REC opinion

  Favourable Opinion