How has quality changed in UK general practice since 2021? A multi-site longitudinal study

Problem

Following a shift to remote care during the COVID-19 pandemic, most UK general practices have reverted partly, but not fully, to in-person consulting. It is time to assess the different domains of quality in this new, ‘hybrid’ model.

Approach

As part of the NIHR-funded Remote by Default 2 (RBD2) study, data were collected from longitudinal case studies of 12 general practices (2021-2023) selected for maximum diversity in location, demographics, and digital maturity. Researchers-in-residence built a relationship with each practice and made multiple visits over 24 months. This ethnographic dataset was supplemented by multi-stakeholder workshops; interviews with policymakers and stakeholders; patient surveys; official reports (GP Patient Survey, Care Quality Commission); and public-domain practice reviews. Data were uploaded onto NVivo, coded thematically, and analysed with reference to the Institute of Medicine quality domains (effectiveness, efficiency, safety, timeliness, patient-centredness, equity) and core features of primary care (first-contact, undifferentiated, holistic, coordinated, comprehensive, longitudinal, relational).

Findings

The current context of general practice is characterised by accumulated financial austerity, loss of resilience (including secondary care pressures and loss of a societal safety net), complex patterns of illness, an increasingly diverse, fragmented, and transient workforce, material and digital infrastructures that are unfit for purpose, and replacement of direct human-to-human interactions with physically distanced, asynchronous ways of working. Against this background, clinicians and staff continue to aspire to traditional values of general practice (relationship-based, holistic, compassionate care, and ongoing support for patients and families) but providing these is increasingly difficult. Digital access and triage systems designed to increase efficiency have, paradoxically, introduced new forms of inefficiency and compromised other quality domains including accessibility, patient-centredness and equity. Whilst traditional in-person long-term condition reviews have been reintroduced in some practices, others rely on remote, asynchronous data entry by patients and fragmented care shared between clinically-qualified staff and assistants with only basic training. Measures to mitigate digital exclusion (e.g. digital navigators) provide help to an extent, but do not compensate for extremes of structural disadvantage. Staff are stressed, demoralised and leaving; quality of clinical care is sometimes compromised; many patients are dissatisfied and frustrated; and we believe there are significant risks to patient safety.Conclusions:Whilst some patients have benefited from ‘hybrid’ care, the overall picture is concerning. Digitisation, distanciation (the tendency of work interactions to become physically distanced and asynchronous), role differentiation, protocolisation and other changes intended to improve services have sometimes had the unintended effect of compromising quality, especially for the most vulnerable patients. In some settings, general practice care is becoming dehumanised, deprofessionalised, clinically compromised, unfulfilling and unsafe.

Consequences

Our findings reveal a system that is approaching—or, in some cases, beyond—breaking point. The substantial risks to patients and the very survival of general practice should be urgently addressed.