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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
A contemporary ontology of continuity in general practice: Capturing its multiple essences in a digital age
Continuity is a long-established and fiercely-defended value in primary care. Traditional continuity, based on a one-to-one doctor-patient relationship, has declined in recent years. Contemporary general practice is organisationally and technically complex, with multiple staff roles and technologies supporting patient access (e.g. electronic and telephone triage) and clinical encounters (e.g. telephone, video and electronic consultations). Re-evaluation of continuity's relational, organisational, socio-technical and professional characteristics is therefore timely. We developed theory in parallel with collecting and analysing data from case studies of 11 UK general practices followed from 2021 to 2023 as they introduced (or chose not to introduce) remote and digital services. We used strategic, immersive ethnography, interviews, and material analysis of technologies (e.g. digital walk-throughs). Continuity was almost universally valued but differently defined across practices. It was invariably situated and effortful, influenced by the locality, organisation, technical infrastructure, wider system and the values and ways of working of participating actors, and often requiring articulation and ‘tinkering’ by staff. Remote and digital modalities provided opportunities for extending continuity across time and space and for achieving—to a greater or lesser extent—continuity of digital records and shared understandings of a patient and illness episode across the clinical team. Delivering continuity for the most vulnerable patients was sometimes labour-intensive and required one-off adaptations. Building on earlier work by Haggerty et al. we propose a novel ontology of four analytically distinct but empirically overlapping kinds of continuity—of the therapeutic relationship (based on psychodynamic and narrative paradigms), of the illness episode (biomedical-interpretive paradigm), of distributed work (sociotechnical paradigm), and of the practice's commitment to a community (political economy and ethics of care paradigm). This ontology allowed us to theorise and critique successes (continuity achieved) and failures (breaches of continuity and fragmentation of care) in our dataset.
Implementation challenges of electronic blood transfusion safety systems: Lessons from an international, multi-site comparative case study
Background: Severe transfusion reactions resulting from errors in matching the correct blood with the correct patient are considered never events. Despite the relative technical simplicity of barcode scanning for patient-blood bag matching, the adoption and universal application of this safety measure are by no means universal. This study highlights the logistical and institutional challenges associated with spreading, scaling up, and sustaining such IT-supported safety measures in healthcare. Study Design and Methods: We report findings from a 5-year, prospective, multi-site case study conducted across one hospital in England and three hospitals in the Netherlands. Ethnographic methods, including interviews and observations, were used at each site to investigate the implementation of barcode scanning-supported safety pathways for blood transfusions. Results: Significant variation was observed across the sites in the adoption and implementation of barcode scanning-supported safety pathways. Despite the potential for reducing transfusion errors, the introduction of this innovation was met with varying levels of success in different settings. Discussion: This study highlights the critical role of inter-hospital learning and flexible system design in successfully implementing barcode scanning-supported safety pathways for blood transfusions. A more structured, national-level network for knowledge sharing could enhance the spread and sustainability of such innovations across healthcare settings.
Airborne infection prevention and control implementation: A positive deviant organisational case study of tuberculosis and COVID-19 at a South African rural district hospital
There are many examples of poor TB infection prevention and control (IPC) implementation in the academic literature, describing a high-risk environment for nosocomial spread of airborne diseases to patients and health workers. We developed a positive deviant organisational case study drawing on Weick’s theory of organisational sensemaking. We focused on a district hospital in the rural Eastern Cape, South Africa and used four primary care clinics as comparator sites. We interviewed 18 health workers to understand TB IPC implementation over time. We included follow-up interviews on interactions between TB and COVID-19 IPC. We found that TB IPC implementation at the district hospital was strengthened by continually adapting strategies based on synergistic interventions (e.g. TB triage and staff health services), changes in what value health workers attached to TB IPC and establishing organisational TB IPC norms. The COVID-19 pandemic severely tested organisational resilience and COVID-19 IPC measures competed instead of acted synergistically with TB. Yet there is the opportunity for applying COVID-19 IPC organisational narratives to TB IPC to support its use. Based on this positive deviant case we recommend viewing TB IPC implementation as a social process where health workers contribute to how evidence is interpreted and applied.
Unravelling the potential of social prescribing in individual-level type 2 diabetes prevention: a mixed-methods realist evaluation
Background: Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector. Preliminary evidence suggests that SP may offer a means of connecting patients with community-based health promotion activities, potentially contributing to the prevention of long-term conditions, such as type 2 diabetes (T2D). Methods: Using mixed-methods realist evaluation, we explored the possible contribution of SP to individual-level prevention of T2D in a multi-ethnic, socio-economically deprived population in London, UK. We made comparisons with an existing prevention programme (NHS Diabetes Prevention Programme (NDPP)) where relevant and possible. Anonymised primary care electronic health record data of 447,360 people 18+ with an active GP registration between December 2016 and February 2022 were analysed using quantitative methods. Qualitative data (interviews with 11 primary care clinicians, 11 social prescribers, 13 community organisations and 8 SP users at high risk of T2D; 36 hours of ethnographic observations of SP and NDPP sessions; and relevant documents) were analysed thematically. Data were integrated using visual means and realist methods. Results: People at high risk of T2D were four times more likely to be referred into SP than the eligible general population (RR 4.31 (95% CI 4.17–4.46)), with adjustment for socio-demographic variables resulting in attenuation (RR 1.33 (95% CI 1.27–1.39)). More people at risk of T2D were referred to SP than to NDPP, which could be explained by the broad referral criteria for SP and highly supportive (proactive, welcoming) environments. Holistic and sustained SP allowed acknowledgement of patients’ wider socio-economic constraints and provision of long-term personalised care. The fact that SP was embedded within the local community and primary care infrastructure facilitated the timely exchange of information and cross-referrals across providers, resulting in enhanced service responsiveness. Conclusions: Our study suggests that SP may offer an opportunity for individual-level T2D prevention to shift away from standardised, targeted and short-term strategies to approaches that are increasingly personalised, inclusive and long-term. Primary care-based SP seems most ideally placed to deliver such approaches where practitioners, providers and commissioners work collectively to achieve holistic, accessible, sustained and integrated services.
Theorising Support for Interdisciplinary Early-Career Researchers Using Communicative Genre and ‘Rules of the Game’
Qualitative social scientists working in medical faculties have to meet multiple expectations. On the one hand, they are expected to comply with the philosophical and theoretical expectations of the social sciences. On the other hand, they may also be expected to produce publications which align with biomedical definitions and framings of quality. As interdisciplinary scholars, they must handle (at least) two sets of journal editors, peer reviewers, grant-awarding panels, and conference audiences. In this paper, we extend the current knowledge base on the ‘dual expectations’ challenge by drawing on Orlikowski and Yates’ theoretical concept of communicative genres. A ‘genre’ in this context is a format of communication (e.g. letter, email, academic paper, and conference presentation) aimed at a particular audience, having a particular material form and socio-linguistic style, and governed by both formal requirements and unwritten social rules. Becoming a member of any community of practice involves becoming familiar with its accepted communicative genres and adept in using them. Academic writing, for example, is a craft that is learned through participation in the social process of communicating one’s ideas to one’s peers in journal articles and other formats. In this reflective paper, we show how the concept of a communicative genre can sensitise us to the conflicting and often dissonant expectations and rule systems governing different academic fields. We use this key concept to suggest ways in which the faculty can support early-career researchers to progress in careers which straddle qualitative social science and medical science.
Why do GPs rarely do video consultations? qualitative study in UK general practice
Background Fewer than 1% of UK general practice consultations occur by video. Aim To explain why video consultations are not more widely used in general practice. Design and setting Analysis of a sub-sample of data from three mixed-method case studies of remote consultation services in various UK settings from 2019–2021. Method The dataset included interviews and focus groups with 121 participants from primary care (33 patients, 55 GPs, 11 other clinicians, nine managers, four support staff, four national policymakers, five technology industry). Data were transcribed, coded thematically, and then analysed using the Planning and Evaluating Remote Consultation Services (PERCS) framework. Results With few exceptions, video consultations were either never adopted or soon abandoned in general practice despite a strong policy push, short-term removal of regulatory and financial barriers, and advances in functionality, dependability, and usability of video technologies (though some products remained ‘fiddly’ and unreliable). The relative advantage of video was perceived as minimal for most of the caseload of general practice, since many presenting problems could be sorted adequately and safely by telephone and in-person assessment was considered necessary for the remainder. Some patients found video appointments convenient, appropriate, and reassuring but others found a therapeutic presence was only achieved in person. Video sometimes added value for out-of-hours and nursing home consultations and statutory functions (for example, death certification). Conclusion Efforts to introduce video consultations in general practice should focus on situations where this modality has a clear relative advantage (for example, strong patient or clinician preference, remote localities, out-of-hours services, nursing homes).
Prevalence of orthostatic intolerance in long covid clinic patients and healthy volunteers: A multicenter study
Orthostatic intolerance (OI), including postural orthostatic tachycardia syndrome (PoTS) and orthostatic hypotension (OH), are often reported in long covid, but published studies are small with inconsistent results. We sought to estimate the prevalence of objective OI in patients attending long covid clinics and healthy volunteers and associations with OI symptoms and comorbidities. Participants with a diagnosis of long covid were recruited from eight UK long covid clinics, and healthy volunteers from general population. All undertook standardized National Aeronautics and Space Administration Lean Test (NLT). Participants' history of typical OI symptoms (e.g., dizziness, palpitations) before and during the NLT were recorded. Two hundred seventy-seven long covid patients and 50 frequency-matched healthy volunteers were tested. Healthy volunteers had no history of OI symptoms or symptoms during NLT or PoTS, 10% had asymptomatic OH. One hundred thirty (47%) long covid patients had previous history of OI symptoms and 144 (52%) developed symptoms during the NLT. Forty-one (15%) had an abnormal NLT, 20 (7%) met criteria for PoTS, and 21 (8%) had OH. Of patients with an abnormal NLT, 45% had no prior symptoms of OI. Relaxing the diagnostic thresholds for PoTS from two consecutive abnormal readings to one abnormal reading during the NLT, resulted in 11% of long covid participants (an additional 4%) meeting criteria for PoTS, but not in healthy volunteers. More than half of long covid patients experienced OI symptoms during NLT and more than one in 10 patients met the criteria for either PoTS or OH, half of whom did not report previous typical OI symptoms. We therefore recommend all patients attending long covid clinics are offered an NLT and appropriate management commenced.
Theorising the shift to video consulting in the UK during the COVID-19 pandemic: Analysis of a mixed methods study using practice theory
We studied video consulting in the National Health Service during 2020–2021 through video interviews, an online survey and online discussions with people who had provided and participated in such consultations. Video consulting had previously been used for selected groups in limited settings in the UK. The pandemic created a seismic shift in the context for remote consulting, in which video transformed from a niche technology typically introduced by individual clinicians committed to innovation and quality improvement to offering what many felt was the only safe way to deliver certain types of healthcare. A new practice emerged: a co-constitution of technology and healthcare made possible by new configurations of equipment, connectivity and physical spaces. Despite heterogeneous service settings and previous experiences of video consulting, we found certain kinds of common changes had made video consulting possible. We used practice theory to analyse these changes, interpreting the commonalities found in our data as changes in purpose, material arrangements and a relaxing of rules about security, confidentiality and location of consultations. The practice of video consulting was equivocal. Accounts of, and preferences for, video consulting varied as did the extent to which it was sustained after initial take-up. People made sense of video consulting in different ways, ranging from interpreting video as offering a new modality of healthcare for the future to a sub-optimal, temporary alternative to in-person care. Despite these variations, video consulting became a recognisable social phenomenon, albeit neither universally adopted nor consistently sustained. The nature of this social change offers new perspectives on processes of implementation and spread and scale-up. Our findings have important implications for the future of video consulting. We emphasise the necessity for viable material arrangements and a continued shared interpretation of the meaning of video consulting for the practice to continue.
Independent SAGE as an example of effective public dialogue on scientific research
The World Health Organization declared COVID-19 to be a public health emergency of international concern on 30 January 2020 and then a pandemic on 11 March 2020. In early 2020, a group of UK scientists volunteered to provide the public with up-to-date and transparent scientific information. The group formed the Independent Scientific Advisory Group for Emergencies (Independent SAGE) and provided live weekly briefings to the public via YouTube. In this Perspective, we describe how and why this group came together and the challenges it faced. We reflect on 4 years of scientific information broadcasting and discuss the guiding principles followed by Independent SAGE, which may be broadly transferable for strengthening the scientist–public dialogue during public health emergencies in future settings. We discuss the provision of clarity and transparency, engagement with the science–policy interface, the practice of interdisciplinarity, the centrality of addressing inequity, the need for dialogue and partnership with the public, the importance of support for advocacy groups, the diversification of communication channels and modalities, the adoption of regular and organized internal communications, the resourcing and support of the group’s communications and the active opposition of misinformation and disinformation campaigns. We reflect on what we might do differently next time and propose research aimed at building the evidence base for optimizing informal scientific advisory groups in crisis situations.
After the disruptive innovation: How remote and digital services were embedded, blended and abandoned in UK general practice - longitudinal study.
BACKGROUND: United Kingdom general practices transitioned rapidly to remote-by-default services in 2020 and subsequently considered whether and how to continue these practices. Their diverse responses provided a unique opportunity to study the longer-term embedding, adaptation and abandonment of digital innovations. Research questions: What was the range of responses to the expansion of remote and digital triage and consultations among United Kingdom general practices in the period following the acute phase of the coronavirus disease discovered in 2019 (COVID-19) pandemic? What can we learn from this example about the long-term impacts of crisis-driven sociotechnical change in healthcare settings? METHODS: We collected longitudinal data from 12 general practices from 2021 to 2023, comprising 500 hours of ethnographic observation, 163 interviews in participating practices and linked organisations (132 staff, 31 patients), 39 stakeholder interviews and 4 multi-stakeholder workshops (210 participants), with additional patient and public involvement input. Data were de-identified, uploaded to NVivo (QSR International, Warrington, UK) and synthesised into case studies, drawing on theories of organisational innovation. RESULTS: General practices' longitudinal progress varied, from a near-total return to traditional in-person services to extensive continuing use of novel digital technologies and pathways. Their efforts to find the right balance were shaped and constrained by numerous contextual factors. Large size, slack resources, high absorptive capacity, strong leadership and good intrapractice relationships favoured innovation. Readiness for remote and digital modalities varied depending on local tension for change, practice values and patient characteristics. Technologies' uptake and use were influenced by their material properties and functionality. Embedding and sustaining technologies required ongoing work to adapt and refine tasks and processes and adjust (or, where appropriate, selectively abandon) technologies. Adoption and embedding of technologies were affected by various staff and patient factors. When technologies fitted poorly with tasks and routines or when embedding efforts were unsuccessful, inefficiencies and 'techno-stress' resulted, with compromises to patient access and quality of care. LIMITATIONS: Sampling frame was limited to United Kingdom and patient interviews were relatively sparse. CONCLUSION: There is wide variation in digital maturity among United Kingdom general practices. Low use of remote and digital technologies and processes may be warranted and reflect local strategic choices, but it may also indicate lack of awareness and a reactive rather than strategic approach to digital innovation. We offer an updated typology of digital maturity in general practice with suggestions for tailored support. FUTURE WORK: The typology of digital maturity could be applied further to identify in more detail the kind of support needed for practices that are at different stages of maturity and are serving different populations. The need for strategically traditional practices in deprived settings should also be explored. FUNDING: This article 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.
Clinical risk in remote consultations in general practice: findings from in-COVID-19 pandemic qualitative research
Background: The COVID-19 pandemic-related rise in remote consulting raises questions about the nature and type of risks in remote general practice. Aim: To develop an empirically based and theory-informed taxonomy of risks associated with remote consultations. Design & setting: Qualitative sub-study of data selected from the wider datasets of three large, multi-site, mixed-method studies of remote care in general practice before and during the COVID-19 pandemic in the UK. Method: Semi-structured interviews and focus groups, with a total of 176 clinicians and 43 patients. Data were analysed thematically, taking account of an existing framework of domains of clinical risk. Results: The COVID-19 pandemic brought changes to estates (for example, how waiting rooms were used), access pathways, technologies, and interpersonal interactions. Six domains of risk were evident in relation to the following: (1) practice set-up and organisation (including digital inequalities of access, technology failure, and reduced service efficiency); (2) communication and the clinical relationship (including a shift to more transactional consultations); (3) quality of clinical care (including missed diagnoses, safeguarding challenges, over-investigation, and over-treatment); (4) increased burden on the patient (for example, to self-examine and navigate between services); (5) reduced opportunities for screening and managing the social determinants of health; and (6) workforce (including increased clinician stress and fewer opportunities for learning). Conclusion: Notwithstanding potential benefits, if remote consultations are to work safely, risks must be actively mitigated by measures that include digital inclusion strategies, enhanced safety-netting, and training and support for staff.
Integrating System Dynamics and Action Research: Towards a Consideration of Normative Complexity Comment on “Insights Gained From a Re-analysis of Five Improvement Cases in Healthcare Integrating System Dynamics Into Action Research”
Holmström and co-authors argue for the value of integrating system dynamics into action research to deal with increasing complexity in healthcare. We argue that despite merits, the authors overlook the key aspect of normative complexity, which refers to the existence of multiple, often conflicting values that actors in healthcare systems have to pragmatically develop responses to in their daily practices. We argue that a better theoretical and empirical understanding of the multiplicity of values and how actors deal with value conflicts in daily practices can enrich discussions about complexity in healthcare. We introduce the alternative methodology of ‘value exnovation’ for action researchers to broaden the scope of system-based thinking and action research in healthcare.