1. Background to the research

1.1 Policy context and COVID-19

In January 2019, the NHS Long Term Plan stated that every patient would be offered the right to access primary care digitally by 2023/24 (NHS, 2019). The Topol Review, published in 2019, cautiously looked at how to prepare the healthcare workforce for delivering this digital future. It recommended that staff receive training in remote triaging, remote consulting, and assessment of patients' digital capacity and modality suitability (Topol E, 2019). The review also found that this training would work best in settings with the following characteristics: sufficient learning infrastructure and culture, adequately resourced to provide dedicated staff time for training, and a pre-emptive approach to training to support staff confidence and readiness (Topol E, 2019).

The 2019/20 General Medical Services (GMS) contract required all general practitioner (GP) practices to implement consultation systems by April 2020 and to offer video consultations by April 2021 (NHS England, 2019). The contract for 2022/23 required that all practices ensure at least a quarter of appointments were available for online booking (Montgomery U, Kanani N. Letter, 2022); 2023/24’s contract extended that to require that all ‘directly bookable’ appointments be available online, as well as by phone or face-to-face (NHS England, 2023). 2022/23’s contract also considered the use of remote consultations (by telephone, video or online) as standard (NHS England, 2023).

In January 2020, under 15% of consultations took place by telephone (Fisher R, Fraser C, 2021), and less than 1% by video or e-consultation (Greenhalgh T, Ladds E, Hughes G and others, 2022). Shortly thereafter, infection control measures introduced to slow the spread of COVID-19 necessitated that UK general practice rapidly scale up the use of remote triage (NHS England, 2019), and shift to remote consulting as the ‘default’ option. These changes were achieved rapidly on a national scale, though there were some significant implementation challenges around patient equity, training, digital literacy for staff and patients, infrastructure, evaluation, and sustainability (Greenhalgh T, Ladds E, Hughes G and others, 2022; Greenhalgh T, Shaw S, Alvarez Nishio A and others, 2022; Greenhalgh T, Shaw S, Alvarez Nishio A and others, 2022; Wherton J, Greenhalgh T, Shaw SE, 2021; Murphy M, Scott LJ, Salisbury C and others, 2021; Murphy M, Scott LJ, Salisbury C and others, 2021).

In March 2021 in England, telephone and video appointments accounted for 54% of total appointments, while face-to-face appointments made up 46% (Murphy and others, 2021). On average, between April 2020 and March 2021, just 54% of appointments were conducted face-to-face) (Fisher R, Fraser C, 2021). By May 2021, remote was no longer the ‘default’, though the Royal College of General Practitioners (RCGP) recommended it be retained as an option (Royal College of General Practitioners, 2021). By February 2023, 70% of all general practice appointments were carried out face-to-face, 27% by telephone, and under 1% by video (NHS Digital, 2023).

The recent NHS Delivery Plan for Recovering Access to Primary Care outlines the strategy for strengthening routes to primary care across modalities, with a significant focus on digital technologies (NHS England, 2023). All patients should now be offered the option of using digital tools, to get in touch with their practice, request an appointment, report symptoms, submit an administrative request, request a review of a known issue, upload photos as requested, and discuss other information. The use of digital tools is a key part of implementing Modern General Practice Access (NHS England, 2023), helping to assess and navigate patients to the most appropriate care thereby improving the management of demand and capacity.

1.2 Previous research on remote triage and remote consultations

The 2016 Wachter Review identified that digital skills and training needed to be levelled up in the NHS (Wachter RM, 2016), triggering the inception of the NHS Digital Academy, which aimed to develop 300 ‘digital change leaders’ to support digital transformation across the NHS (Farrell D, Sood H, 2020). In 2019, the Topol Review then further highlighted the need for widespread healthcare professional training in using digital systems. Since then, the evidence supporting the need and appetite for digital technology training in general practice has grown significantly. This evidence comes from professional bodies, independent organisations, and academic institutions.

Research carried out by the RCGP in September 2020 found that 94% of GPs required better infrastructure and better technologies to deliver quality remote consultations (Royal College of General Practitioners, 2020). 90% of GPs felt they could be efficient in delivering the best health outcomes for their patients through face-to-face appointments, compared with only 18% via online consultations, 46% through video and 75% via phone (Royal College of General Practitioners, 2020). It also found that respondents felt they would increase their workloads with unnecessary follow-ups when consulting remotely (this was the case for 84% of respondents when consulting online, 54% via video, and 39% via phone). 81% of GPs surveyed said they need more training, and 80% said they need more guidance in order to get the most out of remote consultations (Royal College of General Practitioners, 2020). In May 2021, the Royal College of General Practitioners (RCGP) recommended that GPs and practice teams ‘have access to tools, training, guidance and support in routinely using digital tools in their practice’ to improve the skilled use of digital tools in remote triage and remote consulting and be supported to ‘evaluate, refine, and effectively embed’ those new tools (Royal College of General Practitioners, 2021).

In early 2022, The Health Foundation (THF) published a research report which found that only 10% of patient requests indicated a preference for face-to-face consultations and that 72% of all patient requests were initiated online (rather than via phone or face-to-face), indicating high usage of online access and triage platforms, and acceptability for remote consultations (Clarke GM, Dias A, Wolters A, 2022).

The 2022 General Medical Council (GMC) National Training Survey found that less than half of all trainees (47%) had been able to compensate for loss of training opportunities during COVID-19, and just 34% had been provided with effective alternatives to missed training through simulation facilities/exercises (General Medical Council, 2022). It also found that general practice trainers were positive about their role, but some faced challenges in accessing support due to lack of resources, lack of time and lack of awareness (General Medical Council, 2022).

Currently, training is offered across a wide range of platforms, providers, and professional bodies. However, it is not clear how these offers map to current training needs in general practice teams now that the use of remote triaging and consulting tools has stabilised. There is ongoing academic research work to determine the required competencies and capabilities for multidisciplinary teams to deliver remote triage and consulting (Greenhalgh T, Shaw S, Alvarez Nishio A and others, 2022).

1.3 Aims of the research

The research project detailed in this report was developed in 2019 with the aim of undertaking discovery research to support the NHS Digital Academy (DA) and the Primary Care Transformation (PCT) teams at NHS England to develop digital training offers for general practice staff. The focus was on the skills needed for both clinicians and non-clinical staff to safely and confidently use online consultation and triage solutions effectively. Non-clinical staff, such as receptionists and practice managers, were included in the research due to the key role they play in managing patient requests.

Nightingale Design Research worked with the DA and PCT teams to create a project plan in early 2020. In March 2020, the research was put on hold due to the disruption caused by the COVID-19 pandemic and was resumed in August 2020, at which point the project plan was revised to take into account the changes that had occurred since March. Phase 1 of the research (the focus groups and interviews) was run between May to July 2021, and Phase 2 (the survey) was live between 18 January 2022 and 23 February 2022. Analyses of the survey data were performed by Nightingale Design Research and in-house at NHS England. The draft report, as developed in July 2022, was rewritten by researchers from the University of Oxford in May 2023 for publication.

The research aimed to answer 4 key questions.

• What training offers currently exist for front-line general practice staff to support them in using online consultation and triage systems effectively?
• How effective are existing training offers considered to be by general practice staff?
• What are the training needs of general practice staff? In what specific areas would they like to receive training?
• How should training be delivered?