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Background Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them. Setting and sample UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023. Methods Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often ('Safety II' analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts. Results Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions. Conclusion While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations. [ABSTRACT FROM AUTHOR]

Background: Contemporary general practice includes many kinds of remote encounter. The rise in telephone, video and online modalities for triage and clinical care requires clinicians and support staff to be trained, both individually and as teams, but evidence-based competencies have not previously been produced for general practice. Aim: To identify training needs, core competencies, and learning methods for staff providing remote encounters. Design and setting: Mixed-methods study in UK general practice. Method: Data were collated from longitudinal ethnographic case studies of 12 general practices; a multi-stakeholder workshop; interviews with policymakers, training providers, and trainees; published research; and grey literature (such as training materials and surveys). Data were coded thematically and analysed using theories of individual and team learning. Results: Learning to provide remote services occurred in the context of high workload, understaffing, and complex workflows. Low confidence and perceived unmet training needs were common. Training priorities for novice clinicians included basic technological skills, triage, ethics (for privacy and consent), and communication and clinical skills. Established clinicians' training priorities include advanced communication skills (for example, maintaining rapport and attentiveness), working within the limits of technologies, making complex judgements, coordinating multi-professional care in a distributed environment, and training others. Much existing training is didactic and technology focused. While basic knowledge was often gained using such methods, the ability and confidence to make complex judgements were usually acquired through experience, informal discussions, and on-the-job methods such as shadowing. Whole-team training was valued but rarely available. A draft set of competencies is offered based on the findings. Conclusion: The knowledge needed to deliver high-quality remote encounters to diverse patient groups is complex, collective, and organisationally embedded. The vital role of non-didactic training, for example, joint clinical sessions, case-based discussions, and in-person, whole-team, on-the-job training, needs to be recognised. [ABSTRACT FROM AUTHOR]

Background The introduction of remote triage and assessment early in the pandemic raised questions about patient safety. We sought to capture patients and clinicians' experiences of the management of suspected acute COVID- 19 and generate wider lessons to inform safer care. Setting and sample UK primary healthcare. A subset of relevant data was drawn from five linked in- pandemic qualitative studies. The data set, on a total of 87 participants recruited via social media, patient groups and snowballing, comprised free text excerpts from narrative interviews (10 survivors of acute COVID- 19), online focus groups (20 patients and 30 clinicians), contributions to a Delphi panel (12 clinicians) and fieldnotes from an online workshop (15 patients, clinicians and stakeholders). Methods Data were uploaded onto NVivo. Coding was initially deductive and informed by WHO and Institute of Medicine frameworks of quality and safety. Further inductive analysis refined our theorisation using a wider range of theories--including those of risk, resilience, crisis management and social justice. Results In the early weeks of the pandemic, patient safety was compromised by the driving logic of 'stay home' and 'protect the NHS', in which both patients and clinicians were encouraged to act in a way that helped reduce pressure on an overloaded system facing a novel pathogen with insufficient staff, tools, processes and systems. Furthermore, patients and clinicians observed a shift to a more transactional approach characterised by overuse of algorithms and decision support tools, limited empathy and lack of holistic assessment. Conclusion Lessons from the pandemic suggest three key strategies are needed to prevent avoidable deaths and inequalities in the next crisis: (1) strengthen system resilience (including improved resourcing and staffing; support of new tools and processes; and recognising primary care's role as the 'risk sink' of the healthcare system); (2) develop evidence- based triage and scoring systems; and (3) address social vulnerability. [ABSTRACT FROM AUTHOR]

Background: At the start of the COVID‐19 pandemic, guidance was needed more than ever to direct frontline healthcare and national containment strategies. Rigorous guidance based on robust research was compromised by the emergence of the pandemic and the urgency of need for guidance. Rather than aiming to "get guidance right", guidance developers needed to "get guidance right now". Aim: To examine how guidance developers have responded to the need for credible guidance at the start of the COVID‐19 pandemic. Methods: An exploratory mixed‐methods study was conducted among guidance developers. A web‐based survey and follow‐up interviews were used to examine the most pertinent challenges in developing COVID‐19 guidance, strategies used to address these, and perspectives on the implications of the COVID‐19 pandemic on future guidance development. Results: The survey was completed by 46 guidance developers. Survey findings showed that conventional methods of guidance development were largely unsuited for COVID‐19 guidance, with 80% (n = 37) of respondents resorting to other methods. From the survey and five follow‐up interviews, two themes were identified to bolster the credibility of guidance in a setting of extreme uncertainty: (1) strengthening end‐user involvement and (2) conjoining evidence review and recommendation formulation. 70% (n = 32) of survey respondents foresaw possible changes in future guidance production, most notably shortening development time, by reconsidering how to balance between rigour and speed for different types of questions. Conclusion: "Getting guidance right" and "getting guidance right now" are not opposites, rather uncertainties are always part of guidance development and require guidance developers to balance scientific robustness with usability, acceptability, adequacy and contingency. This crisis points to the need to acknowledge uncertainties of scientific evidence more explicitly and points to mechanisms to live with such uncertainty, thus extending guidance development methods and processes more widely. [ABSTRACT FROM AUTHOR]

Controversies are part and parcel of the process of evidence-based interventions represent a problem for any notion of a 'pure' evidence-based intervention outside the purview of issues such as social norms, economic boundaries and moral dilemmas. This paper provides a detailed case-study of the recent debate and controversy regarding the roll out of HIV prophylaxis (PrEP) by the NHS in England. We describe and analyze the legal, scientific and social battles that followed when the NHS first refused to commission PrEP. In many ways they mirror the controversy that emerged during the early access to HIV treatment in the US in the nineties as published in previous research. We add to this body of research by detailing the particularities of the controversy in the UK, the specific role of a discourse on resource use, how opponents morally framed and used the evidence and the productive aspects of certainty and uncertainty. [ABSTRACT FROM AUTHOR]

Background Since 2022, general practice has shifted from responding to the acute challenges of COVID-19 to restoring full services, using remote and digital modalities as well as traditional 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 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 Institute of Medicine domains, Starfield's core features of primary care and sociological and socio-technical theories. Results Quality efforts in UK general practice occur within cumulative impacts of financial austerity, loss of resilience, increasingly complex patterns of illness and need, a diverse and fragmented workforce, infrastructure unfit for purpose, and distanciated ways of working. Providing the human elements of traditional general practice is difficult and sometimes impossible. Triage systems designed to increase efficiency have introduced new forms of inefficiency and compromised other quality domains. Long-term condition management varies in quality; amidst some convenience gains, some practices rely on remote, asynchronous data entry by patients and fragmented care by underqualified staff. Measures to mitigate digital exclusion do not compensate for extremes of structural disadvantage. Many staff are stressed and demoralised. Conclusion Contemporary hybrid general practice features changes with the unintended effect of dehumanising, compromising and fragmenting care. Risks to patients and the core values of general practice should be urgently addressed., (Copyright © 2024, The Authors.)

Competing Interests: Competing interests: None declared.

Background: Contemporary general practice includes many kinds of remote encounter. The rise in telephone, video and online modalities for triage and clinical care requires clinicians and support staff to be trained, both individually and as teams, but evidence-based competencies have not previously been produced for general practice., Aim: To identify training needs, core competencies, and learning methods for staff providing remote encounters., Design and Setting: Mixed-methods study in UK general practice., Method: Data were collated from longitudinal ethnographic case studies of 12 general practices; a multi-stakeholder workshop; interviews with policymakers, training providers, and trainees; published research; and grey literature (such as training materials and surveys). Data were coded thematically and analysed using theories of individual and team learning., Results: Learning to provide remote services occurred in the context of high workload, understaffing, and complex workflows. Low confidence and perceived unmet training needs were common. Training priorities for novice clinicians included basic technological skills, triage, ethics (for privacy and consent), and communication and clinical skills. Established clinicians' training priorities include advanced communication skills (for example, maintaining rapport and attentiveness), working within the limits of technologies, making complex judgements, coordinating multi-professional care in a distributed environment, and training others. Much existing training is didactic and technology focused. While basic knowledge was often gained using such methods, the ability and confidence to make complex judgements were usually acquired through experience, informal discussions, and on-the-job methods such as shadowing. Whole-team training was valued but rarely available. A draft set of competencies is offered based on the findings., Conclusion: The knowledge needed to deliver high-quality remote encounters to diverse patient groups is complex, collective, and organisationally embedded. The vital role of non-didactic training, for example, joint clinical sessions, case-based discussions, and in-person, whole-team, on-the-job training, needs to be recognised., (© The Authors.)

Competing Interests: Competing interests: SW was a guidelines update standing committee member for NICE from 2014 until 2018. FF was a Board member of Guidelines International Network from 2009 - 2013. He led the Norwegian Guideline Secretariat from 2001 - 2006 and has been a member of several Guideline Working Groups nationally and internationally. CH is guideline co-ordinator of the Netherlands Society of Occupational Medicine. SL worked as a guideline methodologist and developer in Australia. FM worked with NICE on clinical guidelines since 2000 and was Director of the Centre for Clinical Practice (responsible for guidelines) at NICE from 2008-2011. BS worked for NICE from 2008 until 2017, advising on the methods of guideline development. She is also the chair of the GIN AID Knowledge Working Group. TZJ was founding co-chair of the AID Knowledge Working Group. He has studied guideline development for about a decade, through multiple externally funded studies.