3. Findings of Phase 1

Version 3, 29 June 2023

The themes drawn out from the qualitative research reflected the experiences and views of the participants we spoke to during the COVID-19 pandemic in May, June, and July of 2021. The views presented below do not represent all general practice staff in the NHS but rather provide insights into th e main themes with regard to staff training needs.

3.1 Non-clinical staff

Of 31 participants, a total of 13 were non-clinical staff including receptionists and administrative staff, practice managers and assistant practice managers, and staff from Clinical Commissioning Groups (CCG) (who are responsible for improving the use of online consultations in primary care). The focus of discussion with non-clinical staff was on gathering patient information and navigating patient requests, to understand their experiences and i dentify key skills and training needs.

3.1.1 Training needs

Engaging and communicating with patients effectively

Engaging effectively with patients was commonly identified as both a key skill and a training need. Participants emphasised the importance of training to understand processes and protocols related to how patient requests are dealt with, including how requests are triaged and how appointments are allocated. The ability to communicate these processes to patients clearly and confidently was further identifie d as a key skill that offered reassurance to patients and built positive relationships between them and the practice.

The level of confidence relating to their own roles and colleagues’ roles was repeatedly cited as a key factor in how successful practices were in supporting patients to access new modalities of care, such as online consultations. Confidence in non-clinical staff’s knowledge and communication skills translated to better communication with patients. Conversely, lack of confidence resulted in minimal and ineffective communication that often led to confusion and resistance from patients, resulting in a slower pace of change.

Call handling training and appropriate decision-making

Participants emphasised the need for receptionists to know how best to adapt to requests depending on the patient’s specific needs, and to communicate this in a similarly tailored way. This will support them in building up their confidence and in engaging with the system and is particularly imp ortant when handling patients who are older, have disabilities, lack digital literacy or access, or are reluctant to use technology.

From a more practical perspective, training in call handling was mentioned as a need. This includes the ability to open a call, get the information needed from the system, and ending the chat swiftly while still making the patient feel heard and understood. Participants commented that some reception staff struggle to ask the correct questions and may spend too long on calls without getting the necessary d etails, making it difficult to make further decisions about the patient’s care.

Relatedly, participants spoke about the importance of operating within the remits of one’s role and understanding what sorts of decisions one can and should make. The need to train non-clinical staff in identifying situations where they should feel empowered to make a decision but also where they should pass the decision onto someone else was identified; a commonly cited example was the opening up of protected appointment slots by receptionists. Suggestions of this training include care navigation training, signposting training, and training in specific protocols that a particular practice employs. This should be the focus of newer staff, rather than those with more experience as this skill develops over time.

3.1.2 Training already received

The amount and type of training participants had received varied considerably, from no training at all to quite extensive training in creating and implementing a care navigation protocol. The following section details:

• the training mentioned
• the training provider
• participants’ view of its usefulness

Care navigation training

The care navigation training participants received was provided by the CCG and was delivered face-to-face (prior to the pandemic). Receptionists were trained to use templates located next to the patient’s biographical details on the patient record; this acted as a guide that prompted them to ask the necessary questions to decide, for example, whether the patient should see a physiotherapist or a GP.

Participants commented that the effectiveness of care navigation training relies on the staff member’s levels of experience and confidence, and the relationship they have with patients, as this influences their ability to explain to the patient why they are more suited to speak to another clinical staff member rather than a GP as may be expected or requested.

‘Red flags’ in call handling and signposting training

Participants were taught from very early on in their training to identify when a patient required urgent medical care and felt confident in their ability to spot such ‘red flags.’ Call handling training was also felt to be helpful as it allowed them to identify where a call could go wrong and helped them avoid using unhelpful phrases or questions when engaging with patients. Some participants also mentioned having completed signposting training but found it hard to keep up to date on what services were available due to frequent changes.

In-house training in the development and use of protocols

In one practice, reception staff worked with clinical staff to develop a pharmacy referral protocol that was built into their patient record system. Receptionists launch the protocol, gather specific information from the patient, click ‘yes’ or ‘no’ on each section of the protocol, and then decide whether that patient’s needs can be suitably addressed by a pharmacist.

Developing this process allowed reception staff to shape the process with clinicians based on their experience and feedback, tailoring it to how they work. This sense of ‘ownership’ meant that they could provide ongoing support to each other as and when it was needed and make changes when required.

A standardised approach to service delivery

A participant had developed and delivered twelve sessions of training to 100 reception staff across a single PCN; the aim of this training was to have a standardised approach to service delivery by using learnings across different practices to inform the design of a system of active signposting that uses a directory of services available on practice websites. This approach sought to prevent patients from going through multiple systems before finding the right care.

Part of the training involved reception staff engaging with their own and each other’s systems, so they could experience what it was like for their patients. This allowed staff to understand how and why patients were getting confused, enabling a better perspective on how to improve the journey for patients. 

3.1.3 Training method preferences

Generally, participants were trained via face-to-face or live online sessions as opposed to pre-recorded or e-learning formats. Although in-person training was preferred, partici pants were open to training being delivered in a range of different ways. Training was 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 both question-asking and observation of others engaging in a skill ‘in real-life’ was cited as especially useful.

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.

3.2 Clinical staff

The 18 clinical staff involved in Phase 1 included representation from General Practitioners (GPs) (n=9), pharmacists (n=5), and nurses (n=4). The focus of the discussions with non-clinical staff was on confidence, challenges, and training needed in remote triage and remote consultation. The analysis focu sed on training needs, training received, and training preferences.

3.2.1 Training needs

Training more staff in care navigation and triaging to improve practice efficiency and staff capacity

Several GPs shared that their practices were struggling to manage patient requests efficiently, leading to GPs being overburdened and potentially impacting patient safety as a result. They cited inefficient workflow systems as the cause and identified the need to train  other staff, including non-clinical staff such as receptionists, in care navigation and even triaging. This was echoed by nurse practitioners in their discu ssions, who felt that their skills were best used for triage and suggested training for other colleagues in the practice to carry out care navigation, particular those who already had a good level of clinical knowledge such as health care assistants, paramedics, and practice nurses.

Both GPs and nurses feel that if general practice staff had more support in understanding how triage could work for different types of clinicians, practices would then be able to use the skills of those clinicians more effectively and ease some of the burden on GPs.

A GP participant shared that their GP colleagues were ‘nervous’ about nurse practitioners engaging in triage. Indeed, some nurses shared in focus groups and interviews that they found certain cases too complex to handle, although they feel largely confident as they had the clinical skills to triage successfully. Although nurses had not received formal triage training, one had developed skills while working in Accident and Emergency and then transferred those skills to general practice by observing a colleague. However, they indicated some formal training should be made available to help further develop triaging skills rather than having to rely on past training or experience, as effective triaging is quite specialised and requires strong and specific communication skills beyond clinical knowledge.

 Developing skills to conduct different modalities of remote consultations effectively

All but one of the GP participants had completed their training entirely using face-to-face consultations. They recognised their struggles adapting to remote consultations, both in terms of clinical skills and effectively communicating with the patient virtually. The majority of GP participants used telephone calls either most or all of the time and very rarely used video; they felt that it was easier to phone the patient and saw video as unhelpful, partly due to the likelihood of technical issues. Only one GP used video consultations in their practice, which they attributed to specific training they received (in this case, the training focussed on how to adapt examination skills over video).

Although GPs generally found telephone consultations useful, they said it often created additional work. For example, if a patient shares a symptom or issue at the last minute, they would have to be invited in for a face-to-face meeting; effectively, this doubles the GP’s workload as they had carried out a full consultation via telephone already and must now do another in-person. While some skills in conducting remote consultations build up over time,  such as knowing what questions to ask and when, GPs identified the need for training that supports decision-making when remotely caring for patients, including the modality to use, how clinical skills translate for that modality, as well as how to manage risk when they cannot ‘see’ the patient and how to handle multiple issues in one remote consultation particularly if it involves other colleagues.

Contrary to GP participants who received primarily face-to-face training, two participants who are pharmacists carried out most or all of their training via remote consultations due to the pandemic (mostly via telephone). However, whilst they were confident in telephone consultations, they were not confident with video consultations. For pharmacists, a key aspect of successful remote consulting is the ability to communicate with patients as they monitor their conditions from home, which would reduce the need for them to come to the practice and improve reporting and monitoring. For instance, some pharmacists found the use of remote blood pressure monitoring and reporting tools as a part of certain online consultation systems useful, as this allowed them to stay updated on patients’ responses to their medications. Both GPs and pharmacists emphasised the usefulness of texting to communicate with patients and to provide information without having to spend time on a phone call and suggested a need for training on when it is appropriate to use text and how to deal with patients who require further engagement.

Nurse participants only engaged in remote consultations through telephone and did not have experience using video or other modalities.

Managing clinical risk virtually

GPs and nurses found it challenging to ask the right questions and to judge whether a patient needed to be seen, as well as whether the patient understood what they were being told when conducting remote consultations. Both groups were especially concerned about risk, particularly for patients who ended up contacting the surgery multiple times or who ended up being passed around to different clinicians.

GPs share feelings of uncertainty about how to deal with patients who bring up additional symptoms throughout the call when they could not ‘eyeball’ them and reassure themselves that the patient could wait for a further appointment. The uncertainty and anxiety caused by this tempted some of them to return to seeing patients entirely face-to-face, as it was easier to deal with unexpected symptoms when the patient was right in front of them. Nurses worried that some of their more junior nursing colleagues were not skilled enough to successfully manage risk in remote situations. In some cases, their colleagues refused to carry out remote consultations because they did not feel confident or safe enough to do so.

3.2.2 Training already received

Skills for carrying out video consultations

The one GP participant who reported receiving video consultation training felt confident and skilled in conducting physical observation and clinical examination using video, which has proven effective, efficient, and convenient for the patient. They felt the training’s focus on tailoring and adapting clinical skills virtually to be particularly valuable.

A trainee GP received online and simulated training in how to set up the technical elements of a video call and how to run a successful video consultation as part of their GP training. They found both types of training very useful but could not put them into practice very much as patients in her practice have resisted using video consults.

Primary care pathway training

Four pharmacists had completed or were in the process of completing primary care pharmacy education pathway training. As part of that qualification, they were trained to structure consultations effectively and take a complete history. Participants felt this training was effective and provided them with the skills they needed to engage successfully with patients, although was lacking in skills relating to remote consultations. Conversely, the remaining participants completed their training during the pandemic and had developed strong telephone consultation skills, but worried that they lacked face-to-face experience and wanted further training in video consultations specifically and relevant self-monitoring technologies to best support their remote consults.

Reviewing colleagues’ telephone consultations

As evidenced by the nursing participants’ experiences, much of the non-clinical aspects of their role involve informal training and learning by doing. For example, one nurse participant who worked in out-of-hours care listened to twenty of their colleagues’ consultations every month as a form of training; doing so allowed them to learn from the pros and cons of each interaction, thereby improving skills such as triaging, risk management, and care navigation over time.

3.2.3 Training preferences

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. Generally, participants agreed that most training could be  delivered remotely via videoconferencing platforms, with the opportunity to observe and provide feedback to one another. 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.