5. Discussion

5.1 New ways of working in general practice

The findings highlight that new ways of working are widespread in general practice. In the survey, 67.6% of non-clinical respondents reported that they gather patient information or navigate patient requests; when completing these tasks, 68% use a template or protocol. Notably, 65.6% of respondents had not received training in this task between January 2020 and February 2022, suggesting a significant training gap. Participants in the qualitative phase reiterated this gap and emphasised the importance of training in building confidence, which they considered critical in successfully supporting patients to access new care modalities.

Of the clinical respondents, 64.5% reported being responsible for triage; of this, a much higher proportion of GPs (89%) conducted triage than nurses (42%). Of the total clinical respondents, 94% reported carrying out remote consultations; of the 6% who did not consult remotely, the majority were practice nurses (33%) and healthcare assistants (21%). Overall, in qualitative discussions, clinical staff (including advanced nurse practitioners and nurse practitioners, pharmacists, and GPs) recognised the value of remote triage and consultation modalities but some were not confident in employing them in practice due to a lack of skills and training.

In the qualitative phase of the study, nurse practitioners and advanced nurse practitioners voiced concerns about managing risk in remote consultations and stated that the skill level of their colleagues was very variable, to the extent that some do not carry out remote consultations at all. This was echoed by general practitioners (GPs); uncertainty and anxiety encouraged some to return to seeing patients entirely in-person. In cases where remote consultation was employed, they used telephone calls and rarely video due to the perceived likelihood of technical issues; GPs found that telephone consultations sometimes created additional work as patients might introduce symptoms later in the call and need to be seen in person anyway. Conversely, pharmacists were confident about carrying out remote consultations, partly because the types of consultations they carry out are specific and well defined such as structured medication reviews. However, like their GP colleagues, video consultations were actively avoided due to a lack of confidence and experience; telephone calls were preferred. 

5.2 Training received

It was clear from both the qualitative and quantitative research that only a limited amount of formal training in gathering patient information, navigating patient requests, triage and remote consultations had been provided to general practice staff between January 2020 and January 2022. While some clinical and non-clinical participants had received specific formal training in relevant tasks, most had developed their skills on the job either by drawing on training they had received in other roles and adapting it or by observing and learning from the skills of colleagues.

In the survey, 50% of respondents (including both clinical and non-clinical roles) had spent under 20 hours completing study or training in the previous 12 months, with only 20% completing more than 50 hours of training. Most of that training was not carried out in protected time.

From January 2020 to when the survey was conducted in January-February of 2022, 35% of non-clinical staff had received training in gathering patient information or navigating patient requests, while 18% of clinical staff had received training in triage. Regarding remote consultations, 17% of clinical staff had received training in carrying out telephone consultations, 15% in video consultations, and 7% in carrying out consultations via written message.

In qualitative discussions, clinical participants detailed a lack of formal training relating to remote triaging and care navigation, adapting consultations to remote modalities (particularly video), and managing clinical risk remotely. Instances where individuals developed related skills involved specialised training as a part of their professional qualifications, one-off training sessions, and learning from colleagues.

5.3 Training received and perceived value

Of the 35% of non-clinical respondents who received training in gathering information or navigating patient requests since January 2020, a range of training types accessed were mentioned in free-text survey responses including training provided by online consultation systems suppliers; informal training provided by peers/colleagues; formal in-house training provided by managers and pharmacists; training provided by Clinical Commissioning Groups (CCGs); and training via a commercial mandatory training organisation. Respondents found training useful when it was tailored to the needs of the practice and real-life scenarios were used. Generally, non-clinical staff were trained via face-to-face or live online sessions as opposed to pre-recorded or e-learning formats.

Survey results show 18% of clinical respondents had received training in triage between January 2020 and February 2022. Within the same time frame, 17% had received training in carrying out telephone consultations, 15% had received training in carrying out video consultations, and 7% had received training in carrying out text/messaging-based consultations. Training modes accessed include informal learning by observation with colleagues; reading instructional emails; watching YouTube videos; and formalised practice training or training from external partners such as the system/software providers or the British Medical Journal (BMJ).

A significant proportion of survey respondents reported that they had provided training to colleagues in the period under study; 45% of clinical respondents, for instance, stated that they were providing training to colleagues in carrying out triage. Free-text survey responses stated this training was most frequently ad hoc and on-the-job support­ and involved staff sitting with each other and providing support, observing each other carrying out tasks, and group sessions carried out within the practice. This finding reflects what was found in the qualitative research – skills are being passed on within practices through peer learning rather than in more formal ways.­­

Overall findings of the study indicated that clinical and non-clinical staff found training useful when it was practical, was tailored to their role and practice, used real-life examples, and provided different avenues for additional information. Suggestions for improvement included having more protected time for training, recordings of training being available for people to catch up on, more regular training updates, more scenario-based training, and more detail and examples.

5.4 Barriers to training

Barriers to training identified in the survey were similar between clinical and non-clinical staff. High workload was the most chosen barrier to completing training or study, with 74% of all survey respondents selecting this option. The second most common barrier was ‘lack of protected time’, while ‘training time clashes’ was the third most commonly chosen option. This reflected what was said in the qualitative discussions – many participants stated their workload was very high and they were struggling to meet the demands of their role, citing this and a lack of protected time as major barriers to training.

5.5 Training needs identified

The survey posed different closed questions regarding training to different staff groups (depending on whether they had clinical and non-clinical roles). The training needs identified by staff are therefore delineated by staff roles below.

5.5.1 Non-clinical staff

Gathering patient information or navigating patient requests

Non-clinical respondents mostly selected the ‘confident’ and ‘very confident’ options regarding tasks involved in gathering patient information or navigating patient requests. Several tasks, however, garnered more ‘not confident’ or ‘somewhat confident’ responses and these responses were grouped together and categorised as reflecting ‘lower confidence’. The results reveal that approximately 30% of respondents reported low levels of confidence in ‘signposting patients to services outside the GP surgery’, approximately 25% in ‘explaining new access routes and processes to patients’, and approximately 22% in ‘identifying patients who need a face-to-face appointment’. When asked in free-text survey questions what aspects of gathering patient information and navigating patient requests they found particularly challenging, the following options were most commonly selected: ‘dealing with patients’ attitudes and demands’, ‘lack of knowledge required to make a decision’, and ‘communication difficulties when engaging with patients’.

Overall, training needs identified in the survey highlight the importance of understanding the availability and provision of services beyond the surgery, and the ability to interpret and understand patient needs in order to appropriately direct them. It also highlights that approximately a quarter of respondents do not feel confident in explaining new access routes to patients. These tasks require an ability to communicate well with patients, which was supported by findings from qualitative discussions, where non-clinical staff (including receptionists and administrative staff, practice managers and assistant practice managers, and staff from CCGs) identified strong communication skills and thorough knowledge of care navigation pathways to be both a key skill and a training need. A lack of training in this area undermined staff confidence in patient communication and patient navigation. This was an issue as participants linked confidence in communication with their levels of success in supporting patients to use new remote consultation modalities. Confidence was seen to build stronger rapport with patients and empower them to engage with new digital tools.

In the qualitative phase, non-clinical participants spoke of the importance of making decisions only when appropriate and the need for colleagues to defer to other staff when necessary (particularly in relation to less experienced reception staff). Both tasks ensure that patients receive the appropriate care and that practice resources are being used efficiently. Participants further reported that while skills to appropriately navigate patients' requests could be developed over time, targeted training in the area would expedite this process and build confidence more effectively. This is especially pertinent for newer reception and administrative staff.

Overall, the 3 most popular training topics chosen by non-clinical staff were:

• how to identify red flags or issues that require urgent medical attention
• use of data and quality improvement methods to understand demand, capacity, and effectively use technologies
• how to support patients who may struggle to use technology due to disability or lack of digital or language skills

5.5.2 Clinical staff

Triaging and remote consultations

In qualitative discussions, clinical participants indicated that capacity was an issue across clinical and non-clinical roles. It was suggested that a means of addressing this issue could be redistributing tasks to more appropriate staff roles and offering training accordingly. For instance, some nurse practitioners felt their skills were best used for triage and suggested formal training for other colleagues in the practice to carry out care navigation (particularly those who already had a good level of clinical knowledge). This was echoed by GPs, who suggest ineffective use of resources has led to them being overburdened and impacting patient safety as a result.

When asked about training topic preferences in the survey, clinical respondents displayed widespread interest in both non-clinical and clinical areas for training.

Respondents chose the following top 3 non-clinical topics.

• Remote communication skills (for example, how to communicate effectively with patients over the phone/video/message, using tone, humour and building rapport).
• Training to keep up to date with changes in your online consultation systems.
• Technical training to use your online consultation platform more effectively.

The top 3 clinical topics were:

• carrying out an effective clinical assessment as part of remote consultation, including remote clinical examination
• managing clinical risk in remote consultations
• rsk stratification and remote chronic disease management (for example, diabetes, high blood pressure), jointly with best practice in remote consultations

Confidence among survey respondents in carrying out triage-related tasks was generally high. Respondents rated themselves as least confident when mitigating digital exclusion and addressing patient access needs. Both GPs and nurses also had lower confidence in identifying safeguarding issues during remote consultations and choosing the correct consultation mode (phone, video, or written messaging).

When asked what aspects of triage they found most challenging, survey respondents mentioned high workload, difficulty meeting patient demand, difficulty supporting patients who struggle with language barriers/low digital literacy, difficulty making decisions and managing risk, and difficulty assessing patients remotely. These difficulties were supported by respondents who supervise colleagues that carry out triage; supervisors reported that it was difficult to manage risk whilst training others.

In qualitative discussions, GP participants identified a need for support in developing an effective care navigation and triage system for their practices, including how to identify which staff can and should carry out care navigation and triage and what skills were needed. Nurses also highlighted the need to identify staff who could develop care navigation skills in order to support triage, but they felt that their less experienced nursing colleagues also needed more basic training particularly in communication skills to develop confidence in carrying out triage in order to manage telephone triage calls effectively.

Regarding remote consultations, a significant majority of clinical survey respondents (94%) reported employing them in practice. These respondents were mostly GPs, nurses, and pharmacists, and they all had slightly different experiences and training needs. GPs exhibited the highest confidence levels across all modalities (phone, video, written messaging), while nurses and pharmacists showed lower confidence in video consultations and written messaging.

When asked about challenges encountered during remote consultations, survey respondents stated literacy and language barriers, problems around communicating and building rapport with patients, remote clinical assessment, duplication of efforts, and the suitability of remote consultations for certain cases.

5.5.3 Digital exclusion

In both the qualitative research and free-text survey comments, clinical staff raised concerns that older people, people with disabilities, and people with low digital literacy could be excluded or disadvantaged by the digital systems involved in both triaging and remote consulting. Participants stated that they did not know how to ensure that people who cannot or will not use digital systems did not get poorer access to care than those that do use them; mitigating digital exclusion was also one of the skills that survey respondents (particularly GPs) felt least confident in. For non-clinical staff, supporting patients who may struggle to use technology (due to insufficient linguistic or digital literacy, or disability) was one of the top three training topics selected, suggesting a desire to receive training in addressing issues of digital exclusion like their clinical colleagues.

5.6 Training delivery preferences

According to non-clinical staff, the 3 most popular choices for how the training is delivered are:

• eLearning module
• live webinar with the opportunity to ask questions
• face-to-face training sessions

Although in-person training was preferred, participants were open to training being delivered in a range of different ways. Several participants suggested that, for more complex skills such as care navigation and building patient relationships, one-off training is ineffective; this is partly due to staff turnover and regular changes in processes and procedures. Ongoing support and regular refreshers were encouraged to keep these skills up to date.

Generally, clinical staff agreed that most training could be delivered remotely via video-conferencing platforms, with the opportunity to observe and provide feedback to one another. GP and nurses found webinars useful for procedural topics, such as the technical setup of a video call but found hands-on and peer learning more useful for complex skills, such as adapting clinical skills to remote consultations and effective virtual communication. Pharmacists did not mention a preferred mode of training delivery. Nurses and pharmacists further mentioned the benefits of having mentors who supported and guided them, particularly more senior colleagues who shared valuable expertise and lessons from their experiences.

According to clinical staff, the 4 most popular choices for how training is delivered are:

• live webinars
• eLearning modules
• face-to-face training sessions
• pre-recorded videos

Additionally, 16% of clinical respondents cited a preference for who delivered their training. These included trusted organisations (for example, the Royal College of General Practitioners (RCGP), specialised hubs, accredited agencies) and experienced trainers, clinicians, and peers.

Across clinical and non-clinical staff roles, high workload and lack of protected time were cited as significant barriers to training or study. An asynchronous form of learning (for example, pre-recorded videos or e-Learning module) during protected and paid learning time could therefore be an ideal approach for various training programmes. Training was also found to be most effective when it went beyond isolated sessions and involved ongoing, personal support from peers and colleagues; training that was tailored to particular working situations and allowed for question-asking, observation of others engaging in a skill, and included ‘real-life examples or scenarios’ was considered especially useful.

5.7 Strengths and limitations

When interpreting the findings of this work, it is important to note several limitations resulting from the study design and circumstances in which the research was conducted. 31 people participated in the qualitative research and 791 people responded to the survey, therefore the results present only a partial picture of the variety of GP practices within the NHS. This project was undertaken during the covid pandemic wherein digital solutions were scaled up rapidly. Due to the pace of implementation, there was a considerable level of heterogeneity in the way the digital solutions were embedded in the work of practices. These data were collected in 2021 and early 2022 (May-July 2021 for Ph ase 1, and January-February of 2022 for Phase 2), and since then, the landscape and use of remote technologies in general practice have continued to shift. Therefore we would suggest considering these results in conjunction with other ongoing research into digital technologies in general practiceGreenhalgh T, Shaw S, Alvarez Nishio A and others, 2022), and evaluations thereof (James HM, Papoutsi C, Wherton J and others, 2021).