Supporting patients with a mental health diagnosis to use online services in primary care. A qualitative interview study

Abstract

Objective

The increase in reliance on online services for general practice has the potential to increase inequalities within some populations. Patients with a mental health condition are one such group. Digital facilitation is defined as a range of processes, procedures, and people, which seek to support NHS patients in using online services. This study aimed to examine the views and experiences of digital facilitation in primary care amongst patients living with a mental health condition.

Methods

Semi-structured interviews were conducted with patients living with a mental health condition, recruited from general practices across England participating in the Di-Facto study. Thematic analysis was conducted on interview transcripts.

Results

Interviews were conducted with ten participants with a mental health condition, recruited from five general practices. Three themes were identified: (1) familiarity with online services; (2) experiences of those using online services; (3) the need for digital facilitation. The need for digital facilitation was identified in the registration for online services, and in trusting online services.

Conclusions

Online services offer convenience for patients, but registration for the use of such services remains a potential area of difficulty. Participants had difficulties with registering for online services and had concerns about trust in using them. Support offered by general practices in using online services needs to be varied and adaptable to meet the needs of individual patients.

Introduction

There has been an increased reliance on online general practice services in the United Kingdom. This push towards online primary care provision includes the drive towards improved choice, convenience, and ease of access in primary care provision. ¹ In practice, this includes online services for making appointments, online consultations, requesting prescriptions and checking medical records.

Recent international evidence suggests that approximately one-third of all GP consultations are related to psychological conditions (such as depression and anxiety). ² The rate of mental health diagnoses increased throughout the COVID-19 pandemic, both via patients being diagnosed with a new condition, but also through relapse in those with pre-existing conditions. ³

Services for patients (including those with mental health conditions) have increasingly moved online^4,5 and remote consultation has become the default approach in general practice. ⁶ These changes towards increased reliance on the online provision of services have potential implications with respect to increasing inequality. One approach which may address this is for general practices to actively support patients and carers in using online services. Digital facilitation is defined as a ‘range of processes, procedures, and personnel which seeks to support NHS patients in their uptake and use of online services’. ⁷

However, U.K. surveys have found that people with mental health difficulties are more likely to experience digital exclusion ⁸ and this is especially the case for those with severe mental illness. ⁹ Therefore, patients with mental health difficulties may need additional support when using online services. In the context of an overall increase in the reliance on digital delivery of healthcare, we explored how patients with mental health conditions experienced digital facilitation.

This study aimed to examine patients’ views and experiences of digital facilitation in general practice amongst individuals living with a mental health condition. This study was part of a larger study (Di-Facto) ⁷ which aimed to identify, characterise and explore the potential benefits and challenges associated with different models of digital facilitation currently in use which are aimed at improving patient access to digital services in general practice in England.

Methods

The main Di-Facto study included a scoping review, ¹⁰ a practice staff survey, a survey of general practice patients, a survey of patients living with mental health conditions, and a qualitative exploration. The qualitative exploration included interviews with stakeholders, a focused ethnographic case study conducted in eight general practices incorporating non-participant observation, document collection and semi-structured interviews with staff and patients and an interview study with patients living with mental health conditions. Findings of all elements of the Di-Facto study are reported elsewhere. ⁷

Here we report on the findings from the interview study with patients living with mental health conditions (referred to throughout this manuscript as the current mental health study), which was conducted in general practices participating in the ethnographic case study, following the data collection and analysis for the main Di-Facto study.

This research is reported using the Standards for Reporting Qualitative Research framework. ¹¹

Ethics

Ethical approval for the main Di-Facto study was obtained from the North East – Newcastle and North Tyneside 2 Research Ethics Committee on 27 April 2021, and HRA approval was obtained in July 2021 (IRAS No. 289425, Protocol No. L01886). An amendment was approved by the ethics committee, for the inclusion of the mental health element of the study (approved 10 May 2022).

A £10 shopping voucher was given to all participants that took part in an interview, by way of thanking them for their time.

Sampling and recruitment

Participants were recruited to the study between July 2022 and November 2022. Participants were eligible to take part if they were identified by their general practice as having a mental health condition, were over the age of 18 and had capacity to consent to the study. Patients were excluded from participation if they had not had a consultation with their general practice within a year, or if they did not have the capacity to consent to the study. Practices that participated in the ethnography element of the main Di-Facto study ⁷ were invited to take part, with a target of recruiting five practices. Practices in the main Di-Facto study, and in the current mental health study were selected for maximum variability in terms of deprivation, location (rural or urban) and list size. Practices that agreed to take part in the current mental health study ran searches of electronic patient records to identify patients with anxiety, depression or severe enduring mental illness from diagnoses or recent prescriptions recorded in general practice records, who had had a consultation within the last year. Results were screened by a member of the general practice clinical staff, to ensure there were no reasons the patients should not be invited to participate (e.g., patients had the capacity to consent, and there were no major life events ongoing (such as a crisis or a bereavement)). After results were screened by a GP for suitability, letters from the practice and participant information sheets were sent to patients by post, inviting them to return a reply slip, telephone or email the research team if they were happy to participate in an interview. Between 50 and 75 invitations were sent out at each practice. We sought to recruit a varied sample of participants, in regard to gender, age, ethnicity, practice and mental health condition.

Data collection

Consent was obtained prior to interviews. Semi-structured interviews were conducted via telephone calls which were recorded using an encrypted Dictaphone. Interview schedules were based on interview schedules developed for the main Di-Facto study of general primary care patients and adapted to cover the views and experiences of patients with a mental health condition (interview schedule can be found in Appendix 1). Discussions with patients and public representatives ensured appropriate suitable language was used. Interviews explored how patients were supported to use online services and how their mental health diagnosis impacted the support they needed.

Interviews were conducted by an experienced qualitative researcher and were transcribed and anonymised using a professional transcription service. Transcripts were checked for accuracy against the audio recordings.

Data analysis

Interviews were analysed using Thematic Analysis, as described by Braun and Clarke in 2022, ¹² which provides a flexible approach to qualitative data analysis. We utilised the coding frame developed during the main Di-Facto study ⁷ and adapted it to include mental health-specific elements.

Braun and Clarke defined thematic analysis with six steps which were applied to the data. ¹² This consisted of (1) familiarising with the dataset and developing a coding framework, (2) coding in line with the coding framework, amending this iteratively, (3) generating initial themes, (4) developing and reviewing themes iteratively, (5) refining, defining and naming themes and (6) writing up.

Steps 1–6 were conducted by the members of the research team most familiar with the data. Themes were identified and the main Di-Facto study team confirmed they were an accurate summary of the data with no additional themes evident.

Results

Ten participants were recruited for the study from five participating practices. Table 1 shows the characteristics of participating practices and Table 2 shows the demographics of patient participants.

Table 1.

Characteristics of practices.

Practice ID	Size (small <6000, medium 6000–12,000, large ≥12,000)	Location	Percentage of ethnic minority patients	Percentage of patient, ≥65 years	Deprivation level (score 1 = high, 10 = low)
B	Small	Urban	85.7%	7.3%	High (1)
C	Medium	Urban	40%	9.4%	High (3)
E	Large	Rural	1.8%	8.3%	Medium (5)
G	Large	Urban	6.4%	19.6%	Low (8)
H	Small	Urban	1%	14.7%	High (2)

Table 2.

Demographics of participants.

Participant	Gender (self-reported gender)	Age	Ethnicity	Mental health condition (as reported by participant)
P01	Female	42	African	Depression
P02	Female	42	White British	Anxiety and depression
P03	Female	28	White British	Anxiety and OCD
P04	Female	65	White British	Anxiety and depression
P05	Female	67	White British	Anxiety
P06	Female	48	White British	Anxiety and depression
P07	Female	60	White British	Anxiety and depression
P08	Female	54	British Pakistani	Depression
P09	Male	39	White British	Anxiety
P10	Female	63	White British	Bipolar disorder

Three main overarching themes were identified: (1) familiarity with online services; (2) the need for digital facilitation; and (3) experiences of those using online services. These themes are summarised in Table 3, will be discussed in turn, and illustrated with representative quotations.

Table 3.

Summary of themes and sub-themes.

Theme	Sub-themes
1. Familiarity with online services
2. The need for digital facilitation	2.1. Distrust of online services
	2.2. Registration for online services
3. Experiences of those using online services	3.1. Comparison with telephone
	3.2. Convenience of online services
	3.3. Supporting access to medication

Familiarity with online services

Participants reported using the practice regularly on account of their mental health condition. Participants who reported being more familiar with online services did not feel they needed support from their general practice in using such services. Participants also reported using general practice services more during periods of crisis with their mental health condition, the necessity to use services increasing their familiarity and confidence with access and online services.

Yeah, yeah, it's really straight forward. Just go on the website and there's a, there's a column. It's, I really, I find it easily signposted … for someone, myself, who's quite, you know, good at using things like that. Yeah, I find it really easy to use. (P03, Female, 28)

But recently over the last year I have, no, sorry, probably about two years, I have probably used my GP surgery a lot more. So. … my anxiety tends to flare up when the big event turning of my life …. I’m not very good at dealing with big things. Like, you know, just feeling overwhelmed. (P02, Female, 42)

Yeah, I think it's because I see the GP a lot … more than normal people …. So sometimes I can see the GP for three, four days. I call today, I call tomorrow, I call the day after. (P01, Female, 42)

For participants that were less familiar with technology, and less confident with online services, many sought help and support from family and friends in using general practice services online.

But my neighbour who's been a fantastic support and is my carer now she has to do, like, make repeat prescriptions and things online for me. (P07, Female, 60)

Well, I don’t do anything online because I haven’t got anything …. My, my daughter, she does shopping on there for me, and booking up doctors’ appointments. (P10, Female, 63)

The need for digital facilitation

Participants reported their experiences of engaging with online services at the general practice and where support or reassurance was needed in order to do so.

Distrust of online services

There was distrust of online services, with fears around the safety and security of data online preventing them from wanting to use online services to communicate with the general practice. Participants expressed the view that their information needs relating to the trustworthiness of online services were not being met, choosing to avoid online services where they felt this distrust.

And although information is put on a computer and it's sent online, it isn’t safe, it isn’t secure, and they need to remember that …. Even with the e-consult, when you’re sending through information about your symptoms and things like that … and personal details … people don’t know who's going to get and who's gonna actually be able to see that piece of information. (P07, Female, 60)

Registration for online services

Registering for online services could be a difficult or long process, and a barrier to wanting to engage in online services at the general practice. Support from the practice was recognised as potentially beneficial in relation to registration. Some participants reported participants required an email address to register and this could be a barrier, adding another complicated step in the process as they were not familiar with technology, did not have an email address and did not know how to set one up. Where participants had to go into the practice to take identification to be able to register for online services, this was a barrier to registration.

There's, there is the thing about registering and I don’t do that so I think at one point that actually, that did put me off. (P09, Male, 39)

I couldn’t just sign up, I had to go in and prove, prove who I was, I suppose. (P06, Female, 48)

Experiences of those using online services

There were discordant views about using online services in general practice; online services could be beneficial and increase accessibility but could be linked with negative experiences.

Comparison with telephone

Using online services at the general practice (such as for making appointments or accessing administrative services) caused less anxiety than trying to access services or make appointments using the telephone, which often involved long waiting times or an inability to get through to the practice on the phone which can cause increased anxiety.

And for me, I find them to, the apps and all that a lot better. I think with my anxiety, I find it harder to call places because the anticipation of, especially the GP surgery, you never know, they’re quite stressful you know. (P02, Female, 42)

there are definitely benefits because, you know, you aren't (…) gonna be left in a phone queue. … so that's obviously gonna have an impact on, on, you know (…), if you’ve got anxiety, particularly if you get that sort of, you know, it's not particularly well set up … phone queuing system and you’re not really sure when you’re gonna get seen at all. (P09, Male, 39)

However, it was still not without issues, for example anxiety caused by having to input data onto a screen.

It doesn’t help at all if you have to look at a screen …. It, makes you more anxious, and the only thing I can think of is actually talking to somebody on the telephone. (P05, Female, 67)

Online services could be less appealing due to not having an interaction with a person at the general practice. These judgements were often made on a case-by-case basis by individuals, with views on when they would prefer to see or speak to a member of staff at the practice.

I think if you have issues around anxiety then the potential disadvantage is that you, you might find it easier to talk to somebody on a phone. (P09, Male, 39)

Cause sometimes they just need that comfort, that face-to-face to tell you it’ll be all right … a computer can’t tell you that, a phone can’t tell you that. (P04, Female, 65)

Convenience of online services

Online services were considered to be easy and convenient by participants who use them, increasing the accessibility for this population. Using online services could be advantageous as they did not have to leave the house to attend appointments. Communicating online meant not having to engage with people, which could be a benefit.

I mean, the benefits of online services that they’re instantly accessible. And so access wise they can help with services and signposting. (P08, Female, 54)

Supporting access to medication

Patients reported online services as being useful for ensuring medication for mental health conditions was accessed in a timely and appropriate way, making the maintenance of regular use of medication easier. Online services also made it easy to make adjustments to medication.

they are meds you can’t do without. If you don’t get them you have to go to hospital to get them. So they are not skippable, you can’t skip. So I find it's really convenient where you order, like, two weeks in advance. You make sure they are there. (P01, Female, 42)

Discussion

Summary of main findings

Patients living with mental health conditions expressed a need for support in using online services in two areas; registering for services and around the distrust they felt when using online services. Fear of using online services may exclude some patients living with a mental health condition from accessing their general practice. Participants reported barriers to reliance on the telephone for accessing general practice services (such as consultations), with difficulties in access exacerbating mental health symptoms for some participants.

Patients living with a mental health condition reported using general practice services frequently, particularly when experiencing periods of crisis with their mental health. This led to increased familiarity with systems and less reliance on help and support. Online services present both challenges and advantages to patients living with a mental health condition, with some reporting online services exacerbating their condition, whilst others report the nature of online services making it easier for them to access their general practice.

Comparison to previous literature

Some participating patients found telephone to be a difficult approach to accessing general practice services, ¹³ whilst some found online services to be convenient and this has been demonstrated in studies across broader patient populations^14,15 where convenience is often context dependent. Registration with online services was a particular concern for participants in this study. Variable rates of registration with online services were observed in a study looking at the NHS app, where registration levels were lower in practices with a high proportion of patients with long term care needs. ¹⁶ There was also variable use of services once registered. ¹⁶ Variable use of online services was observed by the patients in this study, with use being influenced by fluctuations in their condition. Some of the themes identified by participants were in line with findings of the main Di-Facto study, which also identified registration for online services as a barrier to use, and the theme of trust of online services. ⁷

Strengths and limitations

The sample within this study was mostly female, and most had anxiety and/or depression. Despite being common patterns within mental health conditions (e.g., some mental health disorders being more prevalent amongst women), it is acknowledged that experiences for those with other mental health conditions may differ. It is acknowledged that potential stigma around mental health conditions may have prevented some participants from wishing to participate. Future research should consider the potential for this and aim to recruit this population in ways that help encourage a feeling of confidence in participating in research (e.g., talking to people with a mental health diagnosis about where they would feel comfortable hearing about the research, and including other sources of recruitment such as support groups, rather than the general practice). Continued work with PPI groups would support this, and strengthen the steps that were already taken in this research (such as discussing with PPI groups what terminology should be used when discussing mental health).

Some participants who took part reported that they did not necessarily recognise having a formal mental health condition, but reported feeling ‘a bit low’, or ‘a bit anxious’ (despite being coded by their general practice as having a mental health condition, or being in receipt of a prescription for mental health medication). However all the participants that we spoke to understood why they had been identified as eligible to participate, and were able to relate how they felt to the diagnosis they had been listed as having in their medical record. This highlights the importance of clear communication with patients around mental health diagnoses. In addition, one general practice declined participation due to perceiving the topic as too sensitive. This reinforces the need for sensitivity around the topic of mental health, particularly when designing research studies. Despite the relatively small number of participants, the interviews present valuable learning about how patients living with a mental health condition interact with their general practice, and how they feel about using online services for healthcare.

Implications for practice and research

Results from this study suggest that preferences for accessing general practice services vary amongst individuals living with a mental health condition. Some found interactions with online services very positive and helped improve the management of mental health conditions, whilst for others using online general practice services exacerbated symptoms. For this reason, patients should be offered a variety of modes to access general practice appointments and services to suit not only individual patients but adapted to patients whose condition fluctuates.

The study also suggests that the support needed by patients when using online general practice services differs between patients and patient groups. Taking time to understand why patients distrust online services and mitigating this, along with providing support to patients in registering for online services may help this patient group to access online services more confidently.

Some participants did not recognise their condition as a diagnosed mental health condition despite this being in their GP record. This is an important consideration for both research and practice within this population. Sensitivity around using labels or diagnoses is likely to impact patients’ responses or feelings towards their treatment and interaction with healthcare professionals, and also their inclination to participate in research. Effective communication from the general practitioner, and a sensitive approach to language when recruiting for research studies is needed.

Conclusion

There were mixed feelings about the use of online services for general practice services. Some found it preferable to more traditional approaches to services, whereas for others it was a barrier preventing access. This reflects the huge differences that can be found between individuals, and between conditions. Registering for online services and concerns around trust in using them were areas of apprehension for participants living with a mental health condition. Approaches from general practices in the support they offer to patients in using online services need to be varied and adapted to meet the needs of individual patients. Research too in this area needs to account for differences in this population, and a flexible approach to recruitment would be helpful for future studies.

Supplemental Material

sj-docx-1-dhj-10.1177_20552076241255637 - Supplemental material for Supporting patients with a mental health diagnosis to use online services in primary care. A qualitative interview study

Supplemental material, sj-docx-1-dhj-10.1177_20552076241255637 for Supporting patients with a mental health diagnosis to use online services in primary care. A qualitative interview study by Jo Parsons, Gary Abel, Carol Bryce, John Campbell, Jennifer Newbould, Emma Pitchforth, Stephanie Stockwell, Bethan Treadgold, Rachel Winder and Helen Atherton in DIGITAL HEALTH

Supplemental Material

sj-docx-2-dhj-10.1177_20552076241255637 - Supplemental material for Supporting patients with a mental health diagnosis to use online services in primary care. A qualitative interview study

Supplemental material, sj-docx-2-dhj-10.1177_20552076241255637 for Supporting patients with a mental health diagnosis to use online services in primary care. A qualitative interview study by Jo Parsons, Gary Abel, Carol Bryce, John Campbell, Jennifer Newbould, Emma Pitchforth, Stephanie Stockwell, Bethan Treadgold, Rachel Winder and Helen Atherton in DIGITAL HEALTH