Investigating Scottish Long COVID community rehabilitation service models from the perspectives of people living with Long COVID and healthcare professionals: a qualitative descriptive study

Objectives This study aimed to explore the perceptions and experiences of barriers and facilitators to accessing Long COVID community rehabilitation. Design We used a qualitative descriptive design over two rounds of data collection with three participant groups: (1) people with experience of rehabilitation for Long COVID (PwLC); (2) National Health Service (NHS) staff delivering and/or managing community rehabilitation services (allied health professionals (AHPs)) and (3) NHS staff involved in strategic planning around Long COVID in their health board (Long COVID leads). Setting Four NHS Scotland territorial health boards. Participants 51 interviews: eight Long COVID leads (11 interviews); 15 AHPs (25 interviews) and 15 PwLC (15 interviews). Results Three key themes were identified: (1) accessing care for PwLC, (2) understanding Long COVID and its management and (3) strengths and limitations of existing Long COVID rehabilitation services. Conclusions Organisational delivery of Long COVID community rehabilitation is complex and presents multiple challenges. In addition, access to Long COVID community rehabilitation can be challenging. When accessed, these services are valued by PwLC but require adequate planning, publicity and resource. The findings presented here can be used by those developing and delivering services for people with Long COVID.

The knowledge gap is unclear.As the authors state there are already "well documented barriers accessing healthcare services" for people with Long Covid.The stated aims were to explore the perceptions and experiences of i) the barriers and ii) the facilitators to Long Covid rehabilitation services.This question was unclear to medoes it mean barriers and facilitators to referral?Or staying in treatment?Or something else?I was unclear why another study was needed given the existing literature.
Methodologically I was unsure why the authors chose to use "interview topic guides" to inform their interviews.(These were not included in the Supplemental files of the submission -Supplemental file 1 is the COREQ checklist).The Consolidated Framework for Implementation Research guide was specifically designed to answer the sort of questions that the authors asked.The authors should justify why they didn't use this approach.
I was also unclear why they used a convenience sample of people with Long Covid.The authors didn't seek out people who may be underrepresented.I understand all this group had been successfully referred to Long Covid rehabilitation.It might have been more informative to seek out people with Long Covid who hadn't been able to get seen or who were on waiting lists to be seen.
I was also surprised to see that family doctors were not interviewed given that the point of the study was looking at barriers and facilitators to accessing Long Covid clinics (or at least I think access was one of the questions the authors were interested in).
There is also the issue of generalisability.As the authors state the provision of services for Long Covid is evolving.Drawing conclusions from a study done over a year ago in one particular location limits the generalisability of this study to potential readers.I found its conclusions underwhelming and I'm not sure how they would help anyone design or implement Long Covid rehabilitation services.5.The study is limited in terms of generalisability, as discussed in 'implications for practice': "The transferability of key findings from this Scottish -based study should be considered when considering their implications for different clinical and policy contexts."However, we assert that although the study was conducted over a year ago, the findings are relevant as Long COVID services are still developing in Scotland, and beyond, and will perhaps become even more relevant as services need to consider how to respond to short-term Government funding coming to an end.

REVIEWER
We have expanded the section on research and practice implications to provide further clarity of what this paper contributes and where it sits as the first of a series of publications from our larger study.The key findings regarding improved clarity of referral pathways and increased support for services working in remote and rural communities have already been taken on board by policy makers in the Scottish Government.Reviewer 2 1. Methodological decisions with explicit identification of rationale to use this research design and framework analytical approach over other qualitative approaches 2. Sampling frame / exclusions/ data saturation/ data validation or triangulation strategies 3. Temporal and geographical (rural or urban) effect on quality, and accessibility of services and perceptions of stakeholders; as that was a deliberation in this study 4. Rationale of use of TIDieR intervention description categories (as there is no intervention in this study) 5. Methodological/ analytical limitations of this study 6.With respect to analysis, if research team was diverse how were researchers' biases taken care of ? 7. AHPs were also from different professions hence, their perceptions would certainly differ while handling 1.We have added a sentence to study design justifying the use of QD and to data analysis explaining that Framework is congruent with the QD design.
2. Please see response to Editor (point 3) regarding sampling frame & saturation (information power).We have added information on exclusion criteria for each participant group.We have added a comment about triangulation/validity of findings to the 'strengths & limitations' section.
3. We have added further information on the geographical effect of health boards on service delivery in the implications setting of the revised paper.
4. The TIDieR framework was used to enable a comprehensive description of each rehabilitation service.In this context the rehabilitation service model can be conceived of as a service level intervention.
5. We have expanded the limitations section to include the lack of General Practitioners/family doctors and described how we sought "information power" rather than data saturation.Please read and respond to all of the peer review comments.You should provide a point-by-point response to explain any changes you have (or have not) made to the original article and be as specific as possible in your responses.
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GENERAL COMMENTS
Now the paper is well balanced and appropriate for publication.
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