Table 1.

Barriers to general practice access, groups known to experience each barrier, evidence for the impact of digital clinical communication on each barrier, and emerging hypotheses of the impact of digital clinical communication on the barrier in question

Barriers	Groups	Evidence for barriers	Evidence for impact of digital clinical communication on barrier	Hypotheses developed from evidence
Practical access issues	Carers; people with mental health problems	Lack of respite care for care recipients²⁹ Inflexible appointments³⁰ Unknown waiting times³⁰ Service availability³¹ Transport difficulties³¹–³³ Difficulties negotiating appointments and receptionists³⁴ Stress and discomfort of waiting in the waiting room³⁴	E-mail used to contact GP because of its efficiency, speed, and flexibility (for example, patients could use e-mail to communicate with a GP while at work)¹³,³⁵ Carers’ use of digital communication technologies occurs outside of office hours; provide convenient, flexible, and quick ways of accessing information and help⁸⁰ Asynchronous technology can be used to communicate whenever is convenient for the patient, reducing the need to negotiate receptionists or appointment systems, travel to the surgery, and use waiting rooms³⁵–³⁷	Improved access to general practice via digital communication as practical barriers overcome
Lack of candicacy	Carers	Health professionals and carers focus on the needs of the care recipient. The needs of the carer are only considered in terms of what is needed to provide care³⁰,³⁹–⁴²	Identifying oneself as a candidate for health care is necessary before starting the help-seeking process⁴³	Increasing the range of channels through which carers can access general practice will not impact on perceived candidacy
Lack of ability to communicate with health professionals	Refugees and asylum seekers; people with mental health problems	Language barriers affect appointment booking and consultation⁴⁴–⁵⁶ Problematic access to professional interpreters⁴⁴,⁴⁸–⁵⁰,⁵²,⁵⁷–⁵⁹ Confidentiality fears with both professional and informal interpreters⁴⁴,⁴⁹,⁵⁸ Lack of discourse to describe mental health concerns⁶¹,⁶²	Feeling of privacy increased when interpreter is not physically present, increasing patient willingness to discuss sensitive issues; loss of visual information can reduce interpretation quality⁶² People whose first language is not English are not heavy users of digital communication in English-speaking countries¹⁶,⁶³	Communication technology will not change ability of these disadvantaged groups in communicating with health professionals, with the exception being language translation
Patient-related barriers	Refugees and asylum seekers; homeless people; Gypsies and Travellers	Mobility of populations and lack of continuity⁵¹,⁵⁸,⁶⁴ Unwillingness to divulge address (for personal safety, for example, women living in domestic violence shelters, or fear of legal repercussions, for example, failed asylum seekers)⁶⁵ Patients’ lack of knowledge about health service structure and how to access services⁴⁷,⁵⁰	Communication technology facilitates continuity of care¹³,⁶⁶,⁶⁷ Anonymity provided by digital communication could encourage populations who wish to remain hidden to seek help⁶⁶,⁶⁸ No evidence found on the impact on patient knowledge about health services related to the availability of digital communication for clinician–patient communication	Communication technology improves continuity of care for mobile populations and those unwilling to divulge their address Communication technology alone will not improve knowledge about health service structure and how to access services
Negative experiences with healthcare service and staff	People with mental health problems; refugees and asylum seekers; homeless people; Gypsies and Travellers	Staff not seen as sensitive⁴⁴,⁵⁵,⁶⁹–⁷¹ Difficult relationships with GPs⁵¹,⁷¹–⁷³ Negative perceptions of GPs’ knowledge, skills, and empathy for mental health problems³⁴,⁶⁰,⁶¹,⁷⁴,⁷⁵ Distrust in GPs and their abilities⁵¹ Communication difficulties due to mental health problems⁶² Service-wide lack of awareness of patients’ rights and acceptance of official documentation⁵²,⁵⁸	Patients try to see trusted GPs for mental health issues rather than the most available GP,⁷⁷,⁷⁸ prioritising relationship continuity over convenience Text-based communication leaves much room for interpretation, therefore communication between patients and clinicians with well-established relationships is likely to be more successful than that between strangers³⁷,⁷⁹ To build the therapeutic relationship, clinicians and patients need to have face-to-face contact for the richness of stimuli available, for example, auditory, visual, tactile and olfactory³⁷ Social presence theory⁷⁶ states that interpersonal processes are negatively affected by interaction that takes place via media that reduces the feeling of ‘being there’ with each other Digital clinical communication would reduce the need for patients to engage with receptionists and other health centre staff,³⁵–³⁷ ameliorating apprehension about negative experiences with these staff No evidence found that digital communication will in itself improve patients’ trust in the GP, or increase health services’ awareness of patients’ rights	Communication technology will improve continuity of care from a trusted clinician Where there is no existing patient–clinician relationship the use of communication technology will reduce the quality of communication between patient and clinician
Stigmatising and negative reactions to patients	People with mental health problems; refugees and asylum seekers; homeless people; Gypsies and Travellers	Stigma and hostile attitudes (from healthcare staff and other patients)⁵⁰,⁵⁶,⁶⁰,⁷³–⁷⁵,⁸¹–⁸⁴ Embarrassment⁷⁴,⁸⁵,⁸⁶ Fear⁷⁴ Social (dis)approval³¹,⁷³ Perceived discrimination³²,⁷³,⁸⁶	One review suggested that face-to-face consultations were essential for communication about emotional states.⁸⁷ Other evidence suggests that patients do communicate their emotional states with GPs via email,⁸⁸ and are able to discuss embarrassing or sensitive questions⁸⁹ Patients consulting for physical problems can feel less intimidated via video link and able to ask more questions⁹⁰ One review found that teenage girls willingly emailed a health professional in a magazine column to discuss problems/queries that they would not necessarily talk about face to face⁹¹ Online disinhibition theory suggests people express themselves more openly, disclose more, and say things in cyberspace that they would not face to face⁸⁸ The removal of the patient ‘being seen’ seeking help potentially removes the embarrassment, social disapproval, and stigma that some patients may experience at healthcare centres⁶⁸,⁹³	Digital clinical communication will reduce patients’ inhibition and sense of intimidation and promote patient disclosure and asking of questions