Remote-by-Default Care in the COVID-19 pandemic: addressing the micro-,meso-,and macro-level challenges of a radical new service model

Lead Research Organisation: University of Oxford
Department Name: Primary Care Health Sciences


Because COVID-19 is so contagious, the way the NHS works has changed dramatically. For the first time since 1948, you
can't walk into a GP surgery and ask to be seen. You must apply online, phone the surgery or contact NHS111. You may
then get a call-back (phone or video) from a clinician, or a face-to-face appointment, possibly in a 'hot hub'.

These changes to what used to be the family doctor service are radical, frightening and difficult. They cut to the core of
what it is to care and be cared for, and what 'good' and 'excellent' health services look and feel like. Will the doctor be able
to assess you properly by video or phone?

We are an interdisciplinary team specialising in the study of complex, technology-supported change in health and care
settings. Using a variety of methods, we want to do three things:

- Develop tools to help clinicians assess people effectively by phone or video;

- Support the change process through 'action research' - that is, working with GP teams to collect relevant data, analyse it
together and support its rapid use;

- Using collaborative improvement techniques, strengthen the supporting infrastructure for digital innovation in the NHS.


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Greenhalgh T (2022) Why do GPs rarely do video consultations? qualitative study in UK general practice. in The British journal of general practice : the journal of the Royal College of General Practitioners

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Greenhalgh T (2021) Remote by default general practice: must we, should we, dare we? in The British journal of general practice : the journal of the Royal College of General Practitioners

A set of questions and a predictive tool built into electronic records, designed to distinguish people with suspected covid-19 who need to go to hospital from those who can safely be monitored at home. The final RECAP score divides people into 'green' (stay at home, self-monitor), amber (professional monitoring eg via virtual wards with home oximetry), or red (assess in person promptly).

The largest qualitative study to date (over 100 people) of the lived experience of long covid. Their stories, along with other research by other teams, informed academic papers and also key policy changes (NICE guidelines, House of Lords report, new NHS clinics, further research funding).

Case studies of the introduction of remote consultations in UK general practice, along with a framework (PERCS) for planning and evaluating remote consultation services. This case study work led directly to further funding from NIHR HS&DR for 'Remote by Default 2' - a further 2-2.5 years' follow up of 11 GP practices as they struggle with remote appointments.
Exploitation Route Risk score (RECAP) for supporting decisions to send people into hospital with covid-19, is now built into ambulance service templates and some GP systems

PERCS framework for planning and evaluating remote consultation services - can be used to help research or evaluate any digital consultation service
Sectors Digital/Communication/Information Technologies (including Software),Healthcare

Description DISCOVERY 1: TOOL AND TECHNIQUES FOR CLINICAL ASSESSMENT OF ACUTE COVID • We understand that the RECAP score is now embedded in ambulance and out of hours systems for assessment of patients with ? covid. DISCOVERY 2: QUALITATIVE INSIGHTS AND POLICY CHANGE IN LONG COVID • Informed services and policy for long covid (e.g. we were commissioned to write a report for the House of Lords Select Committee; Prof Greenhalgh was on the Oversight Group for NICE guidelines on long covid and also on the National Long Covid Task Force which developed the 5-point plan for long covid, made long covid specialist clinics an NHS priority, and allocated some £40M for further research) DISCOVERY 3: STUDIES OF RAPID INTRODUCTION OF REMOTE SERVICES • Our planning and evaluating remote consultation services (PERCS) framework is used by Scottish, Welsh and English digital transformation teams to inform their work supporting GP practices to provide remote consultations • We produced policy briefings (published by Nuffield Trust, a partner on the grant) which were widely distributed to policy groups in UK • NHS England commissioned us to co-design patient advice leaflets, web resources and a video on how to access and use digital services
First Year Of Impact 2021
Sector Digital/Communication/Information Technologies (including Software),Healthcare
Impact Types Societal,Policy & public services

Description Embedding of RECAP score into national emergency assessment protocols in ambulance and out of hours service
Geographic Reach National 
Policy Influence Type Influenced training of practitioners or researchers
Impact In wave 1 of the pandemic, a big problem was that some people who were very sick with covid-19 didn't get sent to hospital while others who were not very sick did get sent in. This was partly because the people doing the assessments took account of early (dramatic) data on high-risk groups. For example, a male, aged in his 80s and from an Asian background might get sent into hospital even when he didn't have particularly bad symptoms. This would (paradoxically) put him at risk, since hospitals were good places to catch covid from. On the other hand, a young person might be reassured that they were OK even when they were (unusually) extremely sick. We developed the RECAP score to try to improve the discrimination of the questions patients got asked (usually over the telephone) to assess how sick they were and how rapidly they were deteriorating. For example, we determined that it was crucial to assess the *trajectory* of breathlessness as well as the activities the person could no longer do that they could do (for example) a day ago or an hour ago. Using a Delphi design, we produced a draft score (RECAP-0), and this was quickly embedded into the decision algorithms in CCAS. The quantitative component of the study was validating the score against actual outcomes (death from covid-19, ITU admission, overnight hospital admission). The validation study confirmed that this score did indeed predict these outcomes, so the fact that it was widely used in the second and third waves of covid-19 and informed national guidelines suggests that lives were saved and unnecessary hospital assessments avoided. However since it was not possible to do a RCT at the height of the pandemic we'll never know precisely how many of those lives were attributable to the RECAP tools.
Description Long Covid national guideline (NICE) / taskforce (Lord Bethell)
Geographic Reach National 
Policy Influence Type Membership of a guideline committee
Impact Long Covid is a new disease, was poorly understood. I was on the oversight group for a new NICE guideline and also on Lord Bethell's National Long Covid Task Force. From a dreadful situation in mid 2020 when many clinicians didn't even know this disease existed (and some thought it was 'in the mind'), we now have a clear national policy, supported by evidence, and ring-fenced funding for long Covid rehab clinics across the country.
Description Can phenotypes developed from enhanced remote primary care assessment of COVID-19 be used to identify a cohort of community cases, and enable comparison of recovered and long COVID?
Amount £197,314 (GBP)
Funding ID HDRUK2020.139 
Organisation Health Data Research UK 
Sector Private
Country United Kingdom
Start 01/2021 
End 08/2021
Description LOng COvid Multidisciplinary consortium: Optimising Treatments and servIces acrOss the NHS (LOCOMOTION)
Amount £3,419,033 (GBP)
Funding ID COV-LT2-0016 
Organisation University of Leeds 
Sector Academic/University
Country United Kingdom
Start 11/2021 
End 10/2023
Description RECAP (Remote Covid Assessment in Primary Care) 
Organisation Imperial College London
Country United Kingdom 
Sector Academic/University 
PI Contribution I can't find UK pounds on the pull-down menu but we're approaching parity with Euro anyway, sigh. It would be really good if Researchfish changed its currency pull-down menu so we could pick 'UK pounds' as the top selection. As it is, I spent about 20 minutes going up and down. I'm sure the currency is in there but just think of the number of professor-hours wasted on this. We collaborate with Imperial on the RECAP study to validate an early warning score for acute Covid-19.
Collaborator Contribution Imperial are sponsoring because we're both recruiting patients but Imperial don't do joint sponsorship.
Impact Early days
Start Year 2020
Description Animation 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact A short animation co-produced with patients and clinicians 'Why Do a Video Consultation?', aimed at patients who are reticent about consulting with a clinician via video.
Currently at pilot stage - will update next year when wider audience reached.
Year(s) Of Engagement Activity 2020
Description Over 50 TV and radio appearances in 2020 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Exceptional public engagement activity during the Covid-19 pandemic. Over 50 TV/radio appearances to 10 countries including UK, Canada, USA, Kazakhstan, Sweden and more. Explaining aspects of the pandemic to the lay public and debating with policymakers. Led a high-profile campaign for face masks in UK. Also lectured and talked on remote care (linked directly to my Wellcome SI Award). No time to set out all these talks in detail sorry but some on prime time TV for example reached millions.
Year(s) Of Engagement Activity 2020