The illusion of inclusion: digital transformation in general practice

Problem

There is significant impetus towards ensuring the health service provides inclusive and equitable care, including through remote means. Several policy initiatives aim at addressing inequalities for disadvantaged groups and a range of programmes specifically support digital inclusion. In this presentation we draw on two examples of digital ‘transformation’ in general practice to surface persistent challenges with delivering inclusive care remotely and to identify fine-grained practices staff adopt to carefully navigate inclusion.

Approach

We draw on two NIHR-funded, mixed-methods evaluation projects in English general practice. The first focused on the large-scale, top-down, national roll-out of the NHS App (2020-2023) and the second on the small-scale, bottom-up introduction of video and hybrid group consultations (VHGCs) (2022-ongoing). Working with 8 clinical sites, here we primarily combine our qualitative data which included: a) 67 interviews with 25 patients/carers, 40 (non-)clinical staff and 25 decision-makers, b) 4 focus groups with 22 patients/carers, c) observations in 20 group consultations and back-end operational processes (53hrs).

Findings

We observed significant complexity in efforts to establish and maintain inclusion (across its different dimensions). As a top-down policy initiative, national roll-out of the NHS App raised several inclusion challenges for general practice, especially as patients viewed their surgeries as first port of call for queries related to the app. Such inclusion work was made difficult for staff given little resource or training was provided, regular updates meant they found it difficult to keep up with changes, and limited functionality was provided for languages other than English. Despite staff effort to carefully manage inclusion/exclusion boundaries (e.g. reserving offline appointments, creating patient champion roles, restricting frequent users), it was not always clear to patients how exclusionary effects were managed and by whom. In contrast, as a bottom-up initiative, VHGCs were locally and flexibly led by enthusiastic clinicians. Still, significant gaps were identified as staff familiarised themselves with the potential for exclusion in VHGCs, but local implementation offered more opportunities for creatively developing inclusion strategies based on intimate and direct knowledge of patients (e.g. ad hoc testing, IT support, access to local digital inclusion campaigns, adjusting the service model). While in many cases resolving inclusion gaps, these adaptive strategies were by nature informal and ad hoc, which made them challenging to sustain, and in some cases, led to the abandonment of VHGCs and a return to in-person models.

Consequences

In both studies active inclusion work was performed but remained largely unacknowledged in a system under pressure. More emphasis is needed on the multiple ways in which inclusion challenges manifest in technology-supported general practice, on appropriate distribution of responsibility across formal and informal channels, and on opportunities to grow adequate infrastructural support rather than sustain an ‘illusion’ of inclusion through short-term solutions.