Clinical Strategy public research
Carried out by the Surrey Heartlands Research Team.
We would like to thank everyone who kindly contributed to and supported this work.
Methodology and key objectives
The Surrey Heartlands Clinical Strategy is a strategic framework designed to improve health outcomes and healthcare services for the population served by the Surrey Heartlands Integrated Care System (ICS).
The objective of this research is to gather the views and opinions of residents on key topics within our Clinical Strategy, allowing us to tailor the strategy directly to meet the needs of our communities.
To achieve this, between August and September 2023, we hosted four focus groups with 27 public members from across Surrey. Participants were recruited through our Surrey Citizen Panel, ensuring a diverse representation of ages, genders, and locations throughout the region.
Our research questions were based on seven different example scenarios, selected to provide context around four key topics within the strategy:
- Prevention
- Out-of-Hospital Care
- Acute Provider Collaboration
- Research and data.
Additionally, we conducted one-on-one in-depth interviews with individuals representing priority populations, including service users, people with lived experience, key workers, and those with strategic oversight roles.
This approach enabled us to gather valuable insights and ensure that our clinical strategy is responsive to the specific needs and preferences of our residents.
Key findings summary
Prevention
- People report feeling most confident in managing their physical health, however, would like more support in self-managing their mental health.
- People are most open to accessing a healthcare App if recommended by a healthcare professional, is easy to navigate and provides personalised advice.
- However, there was concern App use would exclude people who don’t have and / or don’t want to access a smartphone.
Out of hospital care
- Preference for online appointments highest when it is a routine appointment, it can be offered quicker than an in-person appointment and / or will save on time or travel costs.
- However, the increased use of virtual appointments needs to ensure that the patient remains feeling heard, keeping the 'human' aspect of appointments.
- Booking appointments online verses over the phone seen as most time efficient.
- To increase patient confidence when booking appointments, both online and over the phone, there is a desire for more public knowledge on how the requests are being triaged.
Acute provider collaboration
- Majority express they are willing to travel further to use an elective centre for surgery if it results in a shorter waiting time, however, they voice a concern this will rely heavily on friends / family to support.
- People report feeling either unaware of the variety of healthcare services available or overwhelmed by the options available and not knowing which are best to access. Many often expect a healthcare professional to signpost them to best options.
- People would like to see more public awareness on the options available to them and knowledge on when it is appropriate to access them.
Research and data
- People report feeling uncertain around the use of artificial intelligence (AI) technology in patient facing settings – still feels unfamiliar to many.
- People voice concerns on personal data use and storage within the healthcare system, reporting a lack of confidence and lack of knowledge in the current technology.
- Those with a long-term condition or who routinely experience tests report themselves as the most confident to interpret and receive test results prior to speaking with a healthcare professional.
Detailed findings
Prevention
How do people feel about managing their own health?
When managing their own health, people often turn to Google for advice, with many considering the NHS website as the most reliable source. People generally feel confident in addressing physical health issues, particularly those who have undergone first aid training, even if it was some time ago, as they report feeling very confident.
Accessing their GP is typically viewed as a last resort when symptoms persist, largely due to the difficulties in securing appointments. Instead, many prefer to seek advice from a pharmacy or by calling 111 before contacting their GP.
There is a notable sense of greater concern when caring for the health of family members compared to managing their own health, with some carers prioritising the health of the person they care for over their own due to time pressures.
However, people tend to feel less confident in managing their mental health than their physical health. Mental health and social care advice are often perceived as harder to access, mainly due to long waiting lists and limited availability.
Additionally, discussing mental health with healthcare professionals is often reported as more challenging than discussing physical health, as symptoms are harder to describe, and the topic remains sensitive for many.
Signposting to social groups could provide valuable support in self-managing health, but few people reported being aware of services such as social prescribing.
I would like more talking therapies available ... sometimes it’s nice to have a conversation with someone who's looking after your well-being and can provide ideas on how not to be isolated…you wouldn't need so many medications and could join groups like a singing group that naturally make people feel better in themselves.
Quote from someone living in Surrey Heartlands.
How do people feel about accessing a healthcare programme via an App?
Those with experience using a healthcare App were often recommended it from their GP. Using an NHS App is the preferred option as people feel confident that they are secure and have accurate advice.
What would encourage people to use a healthcare App?
- Clear expectations of what is required from them before joining an online programme.
- Design of the App should be universally accessible and usable – easy to navigate.
- Convenient to include and fit into daily routine – clear instructions that don’t require any extra steps.
People reporting feeling overwhelmed by so many available health Apps 'dilemma of choice'. Would like to see streamlined options that are recommended by a healthcare professional. People feel more confident they are suitable to join an online programme if a professional supports and directs them to it.
It’s a dilemma of choice because there are so many available that people don't know what a good option is ... sometimes the patient wants an expert to choose because otherwise the burden is on me to find out about the service and make sure it's the right one ... it’s not that there aren’t enough options, it’s actually that there may be too many.
Quote from someone living in Surrey Heartlands.
I think the design comes into it … there's a reason why and iPad can be picked up by a three-year-old and an 83, year old, and still be used quite easily within five minutes ... because it's designed to be used by everybody universally ... this must be embedded in a healthcare app.
Quote from someone living in Surrey Heartlands.
Concern that healthcare Apps aren’t suitable for everyone
- Most people are open to using a health-related App, but there is concern that this approach excludes those without smartphones.
- While the introduction of a "tech angel" could address this issue, it would only benefit individuals who can or would be willing to access a smartphone. A tech angel is seen as most beneficial for those who own a smartphone but lack the knowledge to navigate these programmes.
- Additionally, individuals who do not speak English as their first language or have lower literacy levels may also face challenges. While verbal English is often better understood, this is not always reflected in App designs.
- Tech angels have helped by demonstrating how to translate web pages, thereby increasing digital inclusion for some. However, some people with visual impairments may also struggle to use smartphones.
- Teenagers, particularly those whose phones are monitored by parents or carers, may need permission to download certain apps, such as those related to smoking cessation, which raises concerns that they might avoid accessing these services to avoid disclosing their behaviour.
Ultimately, those most open to seeking out appropriate healthcare programmes will benefit the most, whereas individuals who lack the knowledge or time to find these services may miss out.
This highlights the importance of ensuring that access points to healthcare programmes remain varied.
During our focus groups we had some people share their success stories when using a healthcare App
- Couch to 5k App: Joined after it being recommended by friends, wanted to achieve goal of learning to enjoy running. App supported a gradual build up, was very motivating, user friendly and beneficial to provide additional healthy eating advice.
- NHS stop smoking App: Recently joined the App after a colleague suggested it. They found it easy to locate online and it has provided a good first step to smoking cessation. Would like to see a more personalised approach to encourage further use.
- Badger App: Provided maternity health support throughout pregnancy, encouraged more trust in how beneficial and easy to use healthcare Apps can be.
Out of hospital care
How do people feel about receiving online / virtual appointments rather than in person?
Most people report the benefits of online appointments, particularly when they are unable to attend in person due to mobility or transport issues, a point emphasised by those living in rural areas.
Online appointments also help save on parking costs and are seen as more time-efficient, fitting better around personal working hours and lifestyles. This approach is further supported by carers, who may need to arrange additional care provisions when attending in-person appointments.
Typically, there is a preference for online appointments to be used for more routine check-ups. People would like the option of either online or in-person appointments, with many opting for the online option if it is offered sooner than an in-person visit.
However, there is a perception that online appointments can lead to a lack of communication between the patient and the healthcare professional, as they can feel rushed, more direct, and less personal, often leaving the patient feeling unheard.
Alternatively, receiving care and attending appointments within the community can support social health for many, as it offers a more open environment for discussing additional issues that may arise.
Poor video quality and connection difficulties can also make joining online appointments challenging, though there is a belief that confidence in the system will naturally increase as technology improves.
Concerns remain that those with less experience using technology may miss out on these services, often relying on friends or family for help. Some also mention that they prefer visiting walk-in clinics where they can ensure face-to-face contact with a healthcare professional.
How do people feel about attending a virtual appointment?
There is concern that online appointments lose the 'human' aspect that in-person appointments provide.
When you're worried and you need to talk to a doctor or nurse you need that human side. When it's in person they can really read your face and underlying emotions in your voice.
Quote from someone living in Surrey Heartlands.
My doctors surgery do a lot online, by text and over the phone – it is very useful and takes less time but sometimes it feels like it would be better to see someone in person to ensure you are really being heard.
Quote from someone living in Surrey Heartlands.
How do people currently find booking GP appointments?
Booking appointments online vs over the phone is seen as the most efficient method, however, uncertainty remains around the different online booking and triage systems.
When booking appointments online or via an app, people are generally happy to do so, with most preferring the NHS app due to its user-friendly interface and the perception that it provides the highest level of data security.
This system is particularly beneficial for those who are less confident speaking on the phone or who do not have the time to wait in phone queues. However, some people find that online booking systems are only accessible for a limited time, making them difficult to use.
There is also some uncertainty about how the online triage system works, particularly in terms of filtering based on urgency when only a set number of appointments are available.
Some users report feeling overwhelmed by the number of questions asked online to direct them to the correct person or service. Additionally, there is concern that more vulnerable populations, who may be less familiar with online booking systems, could lose out.
When booking appointments via a telephone call, there is a perception that speaking directly with a person may ensure that the appointment is treated with greater urgency. However, the specific times during which people are required to call often do not align with their work or personal schedules.
Many also experience long waiting periods on hold before being able to speak with someone. This process can sometimes make people feel like a nuisance to the GP practice, especially if they must repeatedly call to secure an appointment.
Furthermore, the receptionist-led triage procedures can create pressure on people to self-diagnose before making a call.
People would like more knowledge on how appointments are currently being triaged.
A lot of people seem to label receptionists and undermine their roles ... there's no public knowledge for how they handle and triage our calls. They have the ability to put us forward to the right professionals ... it's about knowing what to ask in order to get want you need from them … but it's trusting the services and the people who are doing that seems to be the way forward.
Quote from someone living in Surrey Heartlands.
It strikes me that there are two core competences. Number one is getting an appointment. and number two, is getting a prescription. If you can get those right and have a diverse range of access points for all the people you serve, then you immediately create a very positive picture of the service.
Quote from someone living in Surrey Heartlands.
Acute provider collaborative
Would people be happy to attend an elective hub for surgery?
Most people are willing to travel further for surgery if it results in a shorter waiting time, as reducing waiting periods is seen as beneficial for both mental and physical health.
Many report that they would find a way to make the journey, typically relying on friends or family if they live farther away.
Those who have used such services, or something similar, recall a very positive and streamlined experience. However, there are some caveats.
Concerns were raised about access for those living further away, as relying heavily on others for support can feel burdensome.
Additionally, there is the financial strain of personal travel costs, and some individuals are unwilling or unable to use public transport, expecting patient transport services to be available to help cover these costs.
However, patient transport services are not always accessible, especially at short notice. These services often run on a timetable, which can be more difficult to coordinate when the hospital is further away. The decision to travel is also influenced by the urgency of the surgery, as people weigh the level of pain against the inconvenience of travelling.
For individuals with dementia, attending appointments at a distance can be particularly challenging, with familiar environments being preferable.
There is also concern that local hospitals could become less accessible if they are serving patients from further afield for specific procedures.
Ultimately, patient choice should remain a priority, as preferences vary from person to person.
My only thing was the accessibility or the ability of people to get the transport. The further away you are, the more you are going to rely on others to help transport there and back, especially if it's surgery where you'll need someone to bring you home. It may well be a shorter wait, but whether that's more beneficial to you and passing the cost of it on to others taking the burden for you. So the elderly, the house bound and disabled people may well have additional hardships as a result.
Quote from someone living in Surrey Heartlands.
How aware are people to the variety of healthcare services currently available?
Most people feel that they are unaware of the full range of healthcare services available to them. They typically search NHS websites or rely on their GP to suggest alternative options.
People express a desire for more signposting and advertising of services before needing to visit a GP.
There is a lack of confidence in knowing when to consult specific healthcare professionals, such as a physiotherapist instead of a GP, with some suggesting that a checklist system would be useful to determine the most appropriate service to access.
Increasing awareness of services has been seen as best achieved when these services come directly into the community to engage with people.
There is also a perception that the burden is on the patient to ensure communication between different services and to keep their healthcare joined up across the system, with many seeking reassurances that the various roles and services are properly coordinated.
Additionally, there is concern that only those who are proactive in managing their own health will benefit from these additional services, as current advertisements seem to only reach people who are actively seeking them, leaving others at risk of missing out.
How would I know I need to see a physio. It could be that I just laid on it wrong and the doctor would say you'll be fine tomorrow, just take a couple of paracetamols. But instead, I've now registered with the physio and taken their time up. Am I going to go back and cancel it or just not turn up?
Quote from someone living in Surrey Heartlands.
Research and data
How do people feel about the use of artificial intelligence in healthcare?
The primary concern regarding the use of artificial intelligence (AI) in healthcare is the lack of human understanding that it brings to patient interactions.
Many believe that AI cannot demonstrate or understand emotions in the same way humans can, raising concerns that it may lead to a 'disconnected' service that fails to provide reassurance for people who are anxious about their health.
Additionally, there is a belief that medical knowledge is often rooted in human experience, making it difficult for AI to connect the dots or explain concepts in various ways that enhance peoples understanding of their healthcare.
Some people also feel that certain AI chat systems are simply ‘not good enough’ and that it will take time to perfect them; thus, they are reportedly not ready for this change and advocate for a gradual introduction of AI to mitigate public concern.
There is a consensus that AI should remain optional and only be used when appropriate, with the majority expressing a preference for its application in supporting healthcare professionals with the analysis of results rather than being employed as a patient-facing tool.
I understand why the NHS might want to look at it as a cheaper option, but we're not there ethically yet, and it's a real issue in society at the moment.
Quote from someone living in Surrey Heartlands.
How do people feel about using personal data to prioritise appointments?
If patient healthcare data was to be utilised for additional purposes, for example prioritising appointments, people would like clear answers to the following questions:
- Why is it being used in this way?
- Where will the personal data be stored?
- How exactly will it be used to prioritise?
- Will the data be shared with organisations outside of surrey heartlands? If not, how can they assure this?
Many people express feelings of uncertainty regarding their understanding of data usage and storage, voicing concerns about data hacking, particularly considering recent news stories.
While individuals are generally willing to share personal data for clinical research purposes, they prefer it to be fully anonymised and not shared with third parties.
There is a strong preference for clinical priority to guide the decision-making process when prioritising appointments.
The system should aim to create a service that enables underserved populations to access appointments on equal terms with others, rather than providing them with more access.
However, there is concern that this system may overlook individuals who are more vulnerable but have chosen not to register as such, fearing stigma or feeling pressured to identify themselves as more vulnerable to gain better access to healthcare.
Many people report feeling guilty about receiving priority service over their peers, along with worries that resentment may arise among those receiving support as a priority, creating additional stigma around the issue.
I trust the NHS but I'm not sure I trust it to act as the gatekeeper of my private data. I don't mind what it does with my anonymized data but with my own private data, do I trust the NHS with that, do I trust anybody? That competence cannot be guaranteed and that's where my anxiety would stem from.
Quote from someone living in Surrey Heartlands.
In an ideal world, providing it's secure and we have faith in the system, the result is great … to help target care a more specifically to those who might need extra help is a clear benefit. But obviously only in an ideal world where we can be confident of how it is all set up.
Quote from someone living in Surrey Heartlands.
How do people feel about receiving online test results prior to speaking with a GP about them?
Individuals with long-term conditions or those who receive routine tests express a strong preference for receiving test results before consulting with a healthcare professional, as they often feel more familiar and confident in interpreting the results on their own.
Many believe that having access to results prior to an appointment is beneficial, as it provides the opportunity to formulate questions they might want to ask.
However, they would like assurance that there is a contact available for immediate concerns that may arise between receiving their results and the appointment.
The system should also be sensitive regarding the information shared; for instance, serious or one-off results should not be disclosed beforehand.
There is a concern that if people are not familiar with the figures presented in their results, it may lead to anxiety and prompt them to search online for explanations, potentially exacerbating their worries.
I think I’d panic because you know, when you're worried about something, you go on Google to look it up and then you start panicking. So, I think if I saw some results and I wasn't too sure what it was, it would lead me to go down that Google path and panic.
Quote from someone living in Surrey Heartlands.
Appendix: Example scenarios
Example scenario 1 (Prevention)
If you were worried about an aspect of your health that didn't need the immediate attention of a medical professional, how confident would you feel in knowing how to look after yourself? This would cover things like a rash, a small cut, or some sort of ache or pain. The sort of thing you might shake off in a day or two.
Example scenario 2 (Prevention)
You would use a smart phone APP (e.g. the NHS APP) for direct access to refer yourself onto a health programme.
For example, this could include joining an online smoking cessation programme or an app for weight management support which would allow you to access to an online peer support group.
Example scenario 3 (Out of hospital care)
Instead of attending in person appointments your care would be managed over the phone or internet by a specialist team of health and social care professionals.
Your local GP would coordinate and organise this and would be supported by hospital specialists when needed.
There would be a large emphasis on using technology to diagnose and treat patients. For example, you may receive care via an online video call.
Example scenario 4 (Acute provider collaborative)
There would be one clinical location, used Surrey wide, as a centre for patients to attend for more common and routine elective surgeries e.g. ophthalmology and orthopaedics.
This elective centre would help increase surgery efficiency with patients attending from several different sites within Surrey to this one location specifically designed for surgeries. This will allow patients to be seen more quickly and create extra capacity so emergency cases do not disrupt elective operations, causing cancellations or delays.
We would like you to imagine that due to this you had to travel further to visit the elective centre for a surgery but would have to wait for a shorter time for your appointment. This would be compared to travelling less far to your local hospital for a surgery however likely having to wait a longer time for the appointment.
Example scenario 5 (Acute provider collaborative)
You are dealing with a painful shoulder.
To gain some support you go online and register to see a physiotherapist. The physio then examines your shoulder and arranges follow ups as necessary. If you require ongoing treatment the same physio service would arrange any tests and then refer you to a hospital specialist.
This specialist appointment could be online, or at a community hub or specialist hospital. If surgery was required, it would be arranged as a day case surgery at the elective centre (this will be one clinical location used surrey wide for patients to attend for more common and routine elective surgeries).
Following this, all post operative follow up would occur back at the community hub near the patient.
Example scenario 6 (Research and data)
Instead of talking in person or over the phone with a GP in real time you would instead talk online with an ‘e doctor’. You would message the ‘e-doctor’ via a chat box on your local GP practice website.
The ‘e-doctor’ would be powered by artificial intelligence and be able to provide healthcare support such as signposting to relevant services or suggested treatments.
Furthermore, AI technology could be used in hospital settings to assist in reading x-rays and brain scans and help free up more time for clinicians.
Example scenario 7 (Research and data)
Surrey Heartlands would develop a system that uses the health data of its citizens and patients to deliver care to the most underserved populations as a priority.
For example, this may include prioritising appointments for people in the local population who are most vulnerable and may not have adequate access to medical care. People from these priority groups may be seen quicker for an appointment than other people.
An underserved population may include a person with disability, this could be a learning disability or a physical disability. It could also be socio-economically or geographically disadvantaged.