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Challenges to quality in contemporary, hybrid general practice a multi-site longitudinal case study

R. Payne,Francesca Dakin,Ellen MacIver,Nadia Swann,Tabitha Pring,Aileen Clarke,Asli Kalin,Lucy Moore,Emma Ladds,Joseph P. Wherton,Sarah Rybczynska-Bunt,L. Husain,Nina Hemmings,Sietse Wieringa,Trisha Greenhalgh

Published 2024 in The British journal of general practice : the journal of the Royal College of General Practitioners

ABSTRACT

Background Since 2022, general practice has shifted from responding to the acute challenges of COVID-19 to restoring full services using a hybrid of remote, digital, and in-person care. Aim To examine how quality domains are addressed in contemporary UK general practice. Design and setting Multi-site, mostly qualitative longitudinal case study, placed in UK national policy context. Method Data were collected from longitudinal ethnographic case studies of 12 general practices (2021–2023), multi-stakeholder workshops, stakeholder interviews, patient surveys, official reports, and publicly accessible patient experience data. Data were coded thematically and analysed using multiple theories of quality. Results Quality efforts in UK general practice occur in the context of cumulative impacts of financial austerity, loss of resilience, increasingly complex patterns of illness and need, a diverse and fragmented workforce, material and digital infrastructure that is unfit for purpose, and physically distant and asynchronous ways of working. Providing the human elements of traditional general practice (such as relationship-based care, compassion, and support) is difficult and sometimes even impossible. Systems designed to increase efficiency have introduced new forms of inefficiency and have compromised other quality domains such as accessibility, patient-centredness, and equity. Long-term condition management varies in quality. Measures to mitigate digital exclusion (such as digital navigators) are welcome but do not compensate for extremes of structural disadvantage. Many staff are stressed and demoralised. Conclusion Contemporary hybrid general practice features changes (digitalisation, physical distancing, extension of roles, and protocolisation) that have had the unintended effect of dehumanising, compromising, and fragmenting care. Policymakers and practices should urgently address the risks to patients and the traditional core values of general practice should be urgently addressed.

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