Inclusion health patient perspectives on remote access to general practice: a qualitative study

Background The COVID-19 pandemic has led to rapid and widespread adoption of remote consultations and triage-first pathways in general practice. However, there is a lack of evidence on how these changes have been perceived by patients from inclusion health groups. Aim To explore the perspectives of individuals from inclusion health groups on the provision and accessibility of remote general practice services. Design & setting A qualitative study with individuals from Gypsy, Roma and Traveller communities, sex workers, vulnerable migrants, and those experiencing homelessness, recruited by Healthwatch in east London. Method The study materials were co-produced with people with lived experience of social exclusion. Semi-structured interviews with 21 participants were audiorecorded, transcribed, and analysed using the framework method. Results Analysis identified barriers to access owing to lack of translation availability, digital exclusion, and a complex healthcare system, which is difficult to navigate. The role of triage and general practice in emergencies often seemed unclear to participants. Other themes identified included the importance of trust, face-to-face consultation options for ensuring safety, and the benefits of remote access, particularly in terms of convenience and saving time. Themes on reducing barriers included improving staff capacity and communication, offering tailored options and continuity of care, and simplifying care processes. Conclusion The study highlighted the importance of a tailored approach for addressing the multiple barriers to care for inclusion health groups and the need for clearer and inclusive communication on the available triage and care pathways.


Introduction
Inclusion health is a term used to describe people who are socially excluded, are affected by multiple risk factors for poor health, and experience stigma and discrimination. 1 Evidence shows that people from inclusion health groups face barriers in accessing and engaging with health and care services, underuse primary and preventive care, and often rely on emergency services when their health needs become acute. [2][3][4][5] Health services are not accommodating to the language, cultural, and practical needs of this population, 6,7 exacerbating the unfair and avoidable differences in health, and resulting in poor health outcomes and significantly higher than average mortality rates. 8 A rights-based approach to health requires that health policy and programmes must prioritise the needs of those furthest behind towards greater equity. 9 The need to address health inequalities has received growing attention within health research and policy settings. 10,11 Concurrently, digital health technologies have grown and been positioned by policymakers as central to the delivery of a fairer healthcare system. 12 The pandemic catalysed the widespread adoption of remote ways of working within the NHS, including general practice. 'Total triage', where all patient requests for GP consultations required some form of triage, and 'remote-by-default' consulting, where a clinician should consult remotely (by online, phone, or video consultation) unless there is a 'clinical exception', were mandated 13 to reduce COVID-19 transmission. There are calls for greater expansion and implementation of such remote ways of working; 14,15 however, digital technologies have been identified as a new determinant of health and there are concerns that they can exacerbate existing inequalities unless carefully governed and implemented. 16,17 There is limited evidence on the barriers to GP access and the impact of the recent changes on inclusion health populations, with existing evidence mainly focusing on migrants and people experiencing homelessness. 18,19 This study aimed to explore the perspectives of people from a wider range of inclusion health groups, bringing to light not only the access issues these patients face but also their suggestions for improvements. The findings can guide work on improving the implementation of digital and remote ways of working within general practice and the experience of care for these populations.

Method
Participatory qualitative research methodology was employed in two urban case study sites (Newham and Tower Hamlets) from June 2021 until January 2022.

Co-production
The study protocol and materials were co-produced with people with lived experience of social exclusion (experts by experience [EbEs]), including experience of homelessness, asylum seeking, sex work, drug addiction, and being a member of the Romani community, to ensure relevance, sensitivity, and applicability. 20 Pathway (Faculty for Homeless and Inclusion Health) facilitated this co-production work, the outputs of which included the participant information sheet, consent form, interview questions, advert for recruitment, and study protocol. Interview questions focused on experience of accessing general practice before and during the pandemic to try and understand the impact of triaging and remote consulting on inclusion health populations. Topics of interest were as follows: a) access to GP care; b) experience of remote interactions; and c) suggestions for improved care.

Qualitative data collection
Healthwatch Tower Hamlets and Healthwatch Newham were recruited through the Healthwatch national team to work with the study research team and perform semi-structured interviews with local service users. Healthwatch's statutory role is finding out what communities want from health and social care, and it has a research governance framework on how to collect qualitative data and obtain informed consent in vulnerable groups. The consent processes, data storage and handling, and participant incentives were agreed in line with the study's ethical approval. Regular meetings were held with the data collection teams to ensure adherence to the study protocol and troubleshoot problems around data collection.
There were two data collection teams, one under Healthwatch Tower Hamlets consisting of three researchers and one from Healthwatch Newham consisting of two researchers. Healthwatch branches used their local expertise to identify local support organisations for inclusion health groups to facilitate the recruitment of study participants. Communications and engagement materials were in lay language and translation services were used when needed. Individual and group interviews were performed in a mixture of face-to-face and remote settings depending on the accessibility needs and preferences of participants. Participants were not known to the interviewers. Interviewees were reimbursed £30 for their time. Interviews were audiorecorded and transcribed, and the anonymised transcripts were shared with the research team for data analysis.

Analysis
The framework method was used for the analysis to allow important themes to be identified with the co-production group, which consisted of non-experts in data analysis. 21 Researchers who had collected the data from Healthwatch were asked to build a coding framework given their familiarisation with the data from performing and transcribing the interviews. The two coding frameworks, one from Healthwatch Tower Hamlets and one from Healthwatch Newham, were then amalgamated into a single framework. The co-production group met and reviewed the framework against a sample of three transcripts and undertook a critical analysis, which resulted in further iteration of the main themes. This process led to a final co-produced framework, which guided the qualitative analysis of the transcripts during the indexing and charting phases.

Sample characteristics
In total, 21 participants were interviewed ( Table 1). Tower Hamlets undertook eight interviews with 11 participants and Newham 10 interviews with 10 participants. All of Newham's interviews were one-to-one interviews but three of them included support workers providing translation. Six of Tower Hamlets' interviews were one-to-one interviews. One was with two participants and one was with three participants who requested to be interviewed as groups. Three of the Tower Hamlet interviews used translators who were present with the participants at the time of interview. The recruitment period was 4 months and challenges were faced recruiting interviewees who were sex workers and from Gypsy, Roma, and Traveller communities.

Experiences of GP access
The key themes identified with illustrative quotes are presented in Table 2.
Most responders expressed a positive experience with GP access pre-pandemic compared with post-pandemic. Post-pandemic, the main negative experiences quoted were long waits on the phone for appointments and difficulties accessing face-to-face appointments.
Some responders, however, felt positive about access to GP care post-pandemic, commenting on fast response times and easy access.
There was divergence of opinion on what were appropriate waiting times, with some participants thinking that 1 week's waiting was excessive. There was also some confusion on whether GP services should deal with emergencies. One-third of responders described the post-pandemic appointment booking process as complex.
Several participants reported feeling respected and not judged, but others described feeling anxious and frustrated when trying to access GP care in the post-pandemic period. A few participants' Prefer not to say 0 (0) Other 0 (0) experiences of GP access had led to them feeling apathetic about accessing primary care while others expressed fear of being blamed if they did not seek GP advice. Several participants expressed an understanding of the challenges GP practices face.

Barriers to access
The themes that emerged are presented in Table 3. Digital exclusion included not having the skills and/or ability to access digital technology. Low income was described by several participants as a barrier to engaging with remote consulting, specifically maintaining a working phone. Accessing remote and online consulting were considered more challenging with a language barrier. Nine participants said they had no difficulties with accessing free Wi-Fi and getting online. However, most participants mentioned needing an advocate or peer support to use digital tools to access GP care, either because of language or digital literacy issues. Problems with translators were reported, including lack of availability, and needing to rely on friends and/or family to access GP care. Participants also mentioned difficulties with registration, including not having proof of identification or address, moving often, and digital-only registration options. Several responders commented on the complexity of the healthcare system with unclear pathways of care.

Triage system
Only six responders were able to describe the triage process at their practice. One participant described a digital-first triage model, and five responders described a receptionist-based triage system.
More than half of the responders required interviewers to explain the term 'triage' to them and how it would apply in practice. Three responders felt that triage was not necessary in the context of general practice because people should not be presenting for emergency care, and therefore everyone should wait the same amount of time. In addition, some responders felt it was inappropriate to have to share their situation with the receptionist, preferring to speak directly to the GP. However, several of the responders felt that triage was necessary and helped GPs prioritise and sort appointment requests. There was an understanding expressed that not all queries needed face-to-face appointments and of the importance of introducing triage-first models during the pandemic to reduce COVID-19 transmission. Table 4 summarises the themes generated.
Digital access and remote consulting Table 5 presents the positive and negative themes identified when asking about GP digital access and remote consulting. Eleven responders acknowledged positive aspects including convenience, enabling tailored and effective care, and protecting from infection. One-third of responders felt that remote consultations could lead to a trusted GP assessment, especially when there is continuity of care.
Sixteen participants expressed negative views around remote consulting. Several participants felt that they couldn't make themselves understood during remote consultations and language barriers were exacerbated, while some also felt more pressured and rushed. Several participants were concerned that if they spoke English as a second language, they could be misdiagnosed based on a remote assessment.
Practical considerations around remote consulting included the lack of private space for holding the remote consultation. In addition, some participants mentioned worsening care efficiency as a result of digitalisation.
More than half of responders felt that remote consultations did not provide the same experience as face-to-face appointments, and several of those found it harder to build trust with clinicians remotely. Several participants felt that face-to-face appointments are needed to provide safe and effective care, with an emphasis on physical examination being key to diagnosis.

Reducing barriers
When participants were asked about how to reduce barriers to GP access they made several suggestions, which are summarised in Table 6 with key themes.  continued on next page Practical system changes suggested were increasing staff capacity, a tailored approach to care, simplified care processes, offering choice of remote and face-to-face options and appointment flexibility, and the availability of interpreters during triage. Continuity of care seemed to be valued by most responders.
Participants also suggested finding ways to better communicate service changes and ensure a compassionate and approachable staff attitude.

Discussion Summary
This study explored the experiences of people from inclusion health groups on access to and use of GP services during the biggest shift to remote care provision. It also identified the barriers to accessing and receiving care, and the potential solutions from the perspectives of service users. The rapid move to GP total triage and remote-by-default consulting seemed to have exacerbated preexisting barriers to access owing to language issues and difficulty navigating the already complex healthcare system. It introduced new barriers owing to digital illiteracy and challenges around privacy, maintaining a good WI-FI connection, and having a working camera phone. Participants indicated this has led to an increasing reliance on others, such as interpreters, support workers, and family members, to navigate the system. There was a perception that face-to-face appointments are needed to provide safe and effective care. Continuity of care seemed to be particularly valued by people from inclusion groups and was recommended as a way of reducing access barriers. The potential benefits of remote access were also recognised, particularly in terms of convenience and saving time, with a preference for telephone over digital ways of communicating. Participants highlighted the importance of a compassionate attitude and a need for a clearer articulation of the available healthcare access points, triage, care pathways, and the role of general practice in emergencies.

Strengths and limitations
The study used co-production methods in its design, and local stakeholders and outreach workers to recruit a diverse group of inclusion health participants. As a result, it managed to capture a wide range of experiences from vulnerable groups of patients who are generally underrepresented in primary care research. Collaborating with Healthwatch, an expert organisation in collecting patient feedback,   continued on next page to undertake the qualitative interviews introduced more rigour and independence, and allowed the study to expand to possible solutions rather than just focusing on identifying barriers to care.
It is acknowledged that the study findings did not include voices from all inclusion health groups. For example, it did not specifically focus on patients experiencing drug and alcohol dependence, partly because of the additional primary care services providing care for these patients. However, it should be noted that interview participants were not homogenous groups representing a single inclusion health group, and although they were identified because of one characteristic linked to their support organisation or local network, several of them reported experiencing multiple causes of social exclusion, including drug and alcohol dependence.

Comparison with existing literature
Several studies have assessed the acceptability, feasibility, efficacy, and practicality of remote consulting, and showed potential benefits to patients and clinicians, but also revealed a higher uptake by younger, more affluent people and raised concerns on its safety and cost-effectiveness. [22][23][24][25][26][27] Very few studies have explored the impact specifically on inclusion health groups, and those who did found similar themes to the present study including the difficulty of patients' building trust and rapport, difficulty maintaining the infrastructure needed for remote consulting, the need for advocates to navigate booking appointments, exacerbation of language barriers, and concerns about the safety and effectiveness of remote clinical assessments. 17,18,28,29 Continuity and trust were mentioned as important and linked to safety by several participants and this is in accordance with other studies. 30,31 Participants' perceptions that face-to-face appointments are needed to provide safe and effective care, with an emphasis on physical examination often being key to diagnosis, seems to be shared by clinicians in other studies. 25,32 However, for appropriate populations, especially once trust is established, remote consultations can be safe and effective. 31

Implications for practice
This study highlights common barriers to care experienced by people from inclusion groups and the variation in experiences, highlighting the importance of a flexible, responsive, and tailored approach to care.
The availability of consultation options needs to coincide with a simplification of care pathways and clarification of the role of general practice for urgent and emergency situations.
Other practical suggestions from study participants included access to interpreters at triage stage and availability of advocates, support workers, and care coordinators who can assist people with difficulties navigating the system. This would require resources and improved system capacity.
The importance of trust, respect, and relational continuity for people from vulnerable groups has been highlighted in this and other studies, and is something that will need to be incorporated when designing new ways of working and models of care.
Clarity of the role of triage and reassurance on confidentiality seemed to be important to participants who expressed ambivalence about discussing their health needs with non-clinicians. Staff training on inclusion health may also help to enhance trust and remove barriers to care.
The findings have shown that digital and remote technologies can potentially advance social justice and reduce health inequalities if they are co-designed with service users and implemented with ethical principles and human rights-based approaches in mind.

Reducing barriers
'Ring someone back and tell them you're expecting a phone call. You may expect a phone call at such a time between what hours. Might be on the hour because sometimes you miss a call, they might be busy with the next person. Just give them that bit of time.' (Traveller) 'I'd say look I know I'm struggling and that, I'm ever so sorry and that, but can you help me just sort this out. Please can I just talk to somebody or something like that, and just try and ask for a tiny bit of support.' (Sex worker) Table 6 Continued

Funding
The study has been funded by Public Participation, NHS England. Victoria Tzortziou Brown is funded by the National Institute for Health and Care Research (reference: NIHR302832).

Ethical approval
Ethical approval for the study has been provided by the Queen Mary University of London ethics committee (reference: QMERC20.332).

Provenance
Freely submitted; externally peer reviewed.