4. Findings of Phase 2

Version 3, 29 June 2023

Phase 2 of this study involved a survey conducted between January 18 and February 23 of 2022. The online questionnaire was open to all general practice staff (both clinical and non-clinical) working in England and included a mix of multiple-choice and free-text questions. Quantitative analysis using natural language processing tools was employed, while free-text responses underwent broad qualitative thematic analysis. This cannot be considered a representative sample due to the self-selection of participants. 

Insights from clinical and non-clinical staff

4.1 Survey respondent characteristics

The survey inquired about a range of respon dent characteristics, including their role and experience therein, and their practice’s region, size, partner number, and deprivation. Respondent roles are outlined in Table 1 below and further expanded upon in Appendix C. 

Table 1

Role	Number of participants*	Percentage (%)
Role Clinical roles
Role Practice Nurse	Number of participants* 108	Percentage (%) 25.9
Role Nurse Practitioner	Number of participants* 20	Percentage (%) 4.8
Role Advanced Nurse Practitioner	Number of participants* 37	Percentage (%) 8.9
Role Physician Associate	Number of participants* 2	Percentage (%) 0.5
Role Pharmacist	Number of participants* 21	Percentage (%) 5.0
Role Locum GP	Number of participants* 10	Percentage (%) 2.4
Role Salaried GP	Number of participants* 52	Percentage (%) 12.5
Role GP Trainee	Number of participants* 3	Percentage (%) 0.7
Role GP Partner	Number of participants* 138	Percentage (%) 33.1
Role GP Trainer/Educator	Number of participants* 65	Percentage (%) 15.6
Role Other	Number of participants* 25	Percentage (%) 6.0
Role Total	Number of participants* 481	Percentage (%)
Role Non-clinical roles
Role Receptionist	Number of participants* 67	Percentage (%) 17.9
Role Administrator	Number of participants* 69	Percentage (%) 18.4
Role Practice Manager/Assistant Practice Manager	Number of participants* 210	Percentage (%) 56.1
Role Social Prescribing Link Worker	Number of participants* 10	Percentage (%) 2.7
Role Care-coordinator	Number of participants* 13	Percentage (%) 3.5
Role Other	Number of participants* 40	Percentage (%) 10.7
Role Total	Number of participants* 409	Percentage (%)

* % of clinical respondents for clinical roles and % of non-clinical respondents for non-clinical roles.

4.2 Training and study hours and barriers

Regardless of their role, respondents were asked about both the amount of training they had received and when this training was undergone (such as, protected time that was specifically allocated for study or training) in the previous 12 months. They were also asked to identify up to 5 factors that may have posed as barriers towards the completion of said training or study.

4.2.1 Hours of training completed over the last 12 months

The data indicate that 395 out of 791 clinical and non-clinical staff (50%) had completed between one and 20 hours of training over the 12 months prior to the survey (January 2021-January 2022), indicating that most respondents have had at least some training. 176 (22.3%) have spent 21-50 hours; 158 (20%) more than 50 hours; and 61 (7.7%) 0 hours. Clinical staff reported to have received comparatively more training than non-clinical in the period under study. Clinicians’ training hours were reasonably evenly distributed between 1-20 hours (33%), 21-50 hours (31%), and more than 50 hours (34%). Conversely, 69% of non-clinical staff reported completing between 1-20 hours of training in the 12-month period prior to being surveyed.

When asked approximately what percentage of their study or training was carried out in protected time, 494 respondents (68.1%) indicated 0-30%; 126 respondents (17.4%) indicated 31-70%; and 105 respondents (14.5%) indicated 71-100%. This suggests that the majority of the training was not carried out in protected time.

4.2.2 Barriers to completing training and study

Respondents were asked to select up to 5 factors that may have prevented completion of their training or study in the past year. As outlined in Figure 1, the top 3 most commonly identified barriers, common across clinical and non-clinical staff, were high workload (83.5%), no protected time (42.5%), and training timings clashing with other work responsibilities (38%). 

Figure 1: Responses to the question ‘Have any of the following factors prevented you from completing training or study in the past year?’

Figure 1

Barrier	N	Percentage (%)
Barrier High workload	N 586	Percentage (%) 83.5
Barrier No protected time	N 298	Percentage (%) 42.5
Barrier Timings clashed	N 267	Percentage (%) 38
Barrier Personal circumstances	N 186	Percentage (%) 26.5
Barrier Not meeting needs	N 120	Percentage (%) 17
Barrier Not enough info	N 118	Percentage (%) 16.8
Barrier No funding	N 98	Percentage (%) 14
Barrier No support	N 53	Percentage (%) 7.5
Barrier Other	N 20	Percentage (%) 2.8

N = 1,756 responses from 702 respondents.

 

Insights from non-clinical staff

The following sections (4.3, 4.4, 4.5) draw on data from survey questions that were asked only of non-clinical respondents.

4.3 Gathering patient information or navigating patient requests

Out of the 374 non-clinical respondents, 253 (67.6%) answered yes to whether they are responsible for gathering information from patients or navigating patient requests; the most common role of these respondents are practice managers or assistant practice managers (53.3%), followed by receptionists (19.1%) and administrators (15.1%). Additional respondents include care co-ordinators (2.2%), social prescribing link workers (2.2%), and other roles (8.0%). It is worthwhile to note that amongst those who gather patient information or navigate patient requests, 167 (68%) use a list of questions, protocol, or template, while 77 (32%) do not.

4.3.1 Confidence when gathering patient information or navigating patient requests

Respondents were asked to rate their confidence on a range of tasks associated with the role of gathering patient information and navigating patient requests, as outlined in Figure 2.

While the majority of respondents rated themselves as confident or very confident across all tasks, there were several tasks involved in gathering patient information or navigating patient requests that respondents reported low levels of confidence in. Namely, 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.’

Figure 2: Responses to the question ‘How confident do you feel completing these tasks?’

For each task, a small proportion of respondents (between 4 to 19 participants) selected ‘not applicable,’ indicating that the task was likely unrelated to their specific role; there was no pattern to the roles of these respondents, as it included practice managers, receptionists, and administrators.

4.3.2 Aspects of gathering patient information that are challenging

When asked whether there are aspects of gathering patient information or navigating patient requests that are challenging, 35% of respondents answered yes and were then asked to describe what these were, including any specific challenging scenarios, in a free-text answer. Analysis of these data highlighted the following themes:

• negative patient attitudes and unrealistic/unsuitable patient demands
• lack of knowledge and information required to make a decision
• communication difficulties when engaging with patients

Other issues mentioned include limited clinical resources; issues with IT systems; heavy workload; lack of knowledge around signposting; difficulties with training new staff; issues with understanding clinical pathways; and notably staff not knowing how to deal with urgent or significant mental health needs.

4.3.3 Previous training received on gathering patient requests

The majority of respondents (65.6%) had not received any training in gathering patient information or navigating patient requests between January 2020 and when the survey was conducted between January and February 2022. Notably, although 99% of receptionists report that they gather information from patients or navigate their requests as a part of their roles, 35% who had not received training in this area had been in general practice for less than 2 years; this suggests a training gap whereby receptionists are undertaking tasks without having completed any relevant training.

Of the 35% of respondents who had received training, a range of training types were mentioned 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 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 examples or patient scenarios were used.

When asked whether they engaged with any other learning activities (rather than training) that helped develop their skills in gathering patient information or navigating patient requests, 32% of respondents answered yes. These included reading and peer discussions, webinars from suppliers, discussions at PCN meetings and training, as well as brainstorming within the reception team.

4.3.4 Supervising colleagues who gather patient information or navigate patient requests

64% of non-clinical respondents indicated they were responsible for supervising colleagues who gather patient information or navigate patient requests. Within this group of respondents, 114 (47.9%) indicated they found certain aspects pertaining to supervision challenging. When asked to describe these challenging aspects. Analysis of these data highlighted the following themes.

• Knowledge about navigating and signposting to external services.
• Staff taking different and inconsistent approaches.
• Lack of clinical knowledge.
• Lack of time to provide training.
• Difficulty supporting staff in dealing with uncooperative patients.
• Colleagues’ resistance to change.

4.3.5 Training received in supervising colleagues who gather patient information or navigate patient requests

Only 30 out of 238 respondents (13%) who supervise colleagues that gather patient information or navigate patient requests had received training in carrying out this supervision between January 2020 and when the survey was completed in January-February 2022. The training received came from a wide range of providers including: NHS England North West (previously HEE North West); Time for Care team at NHS England and NHS Improvement; School of General Practice; NHS Leadership Academy; CCG; discussions with practice managers and GPs; and a commercial provider.

Regardless the provider, respondents found certain aspects of the training useful including how it expanded their understanding of the barriers patients experience when accessing care and being provided with suggestions regarding how to provide support to staff.

Suggestions for how the training could be improved included more hands-on training with real-life examples, making modules more specific to non-clinical staff, and more regular training involving the whole team.

53% of all non-clinical respondents provide both formal or informal training to their colleagues on gathering patient information and navigating patient requests. This training included:

• internal case study analysis
• training for new starters on red flags, signposting, systems
• learning through practising examples
• mentoring and coaching
• scenario-based training and developing protocols
• weekly/monthly meetings to identify problems and develop solutions
• training meetings with GP partner

The majority of these respondents (77.4%) felt either confident or very confident about training their colleagues; approximately 23% of respondents, however, indicated they were somewhat confident or not confident.

4.4 Training topics and delivery preferences chosen by non-clinical staff

All non-clinical respondents were asked about topics on which they would like to receive training, as outlined in Figure 3.

Figure 3: Responses to the question ‘Which of the following training topics would interest you?’

The 3 most popular training topics, irrespective of respondents’ roles, were:

• how to identify red flags or issues that require urgent medical attention
• how to use of data and quality improvement methods in order 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

When asked the preferred method for training delivery in future, the three most popular choices were:

• eLearning module
• live webinar which includes the opportunity for participants to raise questions
• face-to-face training sessions

Other modes of delivery included written guidance/example protocols; pre-recorded video(s); direct observation (or listening to call recordings) and peer feedback; and action learning sets or peer forum.

4.5 Final comments of non-clinical staff

Respondents were asked for final comments about training to support gathering of patient information and the navigation of patient requests. Their free-text responses were analysed and the most common comments touched on the need for locally relevant and current training that is consistent across localities, particularly for complex skills, as well as protected time allocated towards completing trainings. There is also a suggestion that patient education should be improved: patients should be encouraged to ‘train’ in their own care navigation and to access more information to understand why they are being referred down a certain path.

Insights from clinical staff

The following sections (4.5, 4.6, 4.7, 4.8) draw on data from survey questions that were asked only of non-clinical respondents.

4.6 Remote triage

Clinical staff respondents (n=417) were asked about their remote triaging responsibilities, any relevant training they had received, and challenges they had experienced. 64.5% of the respondents who identified as clinicians stated that, as part of their role, they were responsible for carrying out triage; this is broken down in Table 2. A much higher proportion of GPs (89%) reported being responsible for triage compared to nurses (42%).

Table 2

	Responsible for Triage (%)	Not Responsible for Triage (%)
Respondents (Role)	Responsible for Triage (%) 64.5*	Not Responsible for Triage (%) 35.5*
GP Partner	Responsible for Triage (%) 50.6**	Not Responsible for Triage (%) 7**
Salaried GP	Responsible for Triage (%) 15.3**	Not Responsible for Triage (%) 4.2**
Locum GP	Responsible for Triage (%) 2.8**	Not Responsible for Triage (%) 0.7**
GP Trainee	Responsible for Triage (%) 0.4**	Not Responsible for Triage (%) 1.4**
Practice Nurse	Responsible for Triage (%) 10.4**	Not Responsible for Triage (%) 56.3**
Advanced Nurse	Responsible for Triage (%) 11.2**	Not Responsible for Triage (%) 4.2**
Practitioner	Responsible for Triage (%) 4.4**	Not Responsible for Triage (%) 4.9**
Nurse Practitioner	Responsible for Triage (%) 1.6**	Not Responsible for Triage (%) 11.3**
Pharmacist	Responsible for Triage (%) 3.2**	Not Responsible for Triage (%) 9.9**

* % of total clinical respondents

** % of responsible/not responsible triage

4.6.1 Confidence in tasks relating to remote triage

Clinical staff confidence levels in tasks associated with remote triage and consulting varied, as outlined in Figure 4. Across roles, respondents felt least confident about mitigating digital exclusion and addressing patient access needs. Both GPs and nurses also had lower confidence in identifying safeguarding issues and choosing the correct consultation mode (phone, video, or written messaging). Overall, respondents felt most confident about identifying red flags and issues that require urgent medical attention.

A comparison of confidence levels in nursing roles versus GP roles revealed that individuals in nursing roles (with the exception of practice nurses, who did not commonly triage patients) had slightly greater levels of confidence across all triage and remote consulting tasks compared to those in GP roles. The most significant difference was in relation to their reported confidence in mitigating digital exclusion and patient access needs.

Figure 4: Responses to the question ‘How confident do you feel in completing these tasks?’

4.6.2 Challenges experienced in relation to triage

60% of respondents stated that there were aspects of carrying out triage that they find challenging. Free-text responses were collected regarding the most challenging aspects of triage. Analysis of these data revealed the following themes.

• Lack of resources (time, appointments, staff).
• Volume of work.
• Literacy and language barriers (linguistic and digital capabilities).
• Risk management and decision-making amidst uncertainty.
• Communication barriers (body language, non-verbal, rapport).

However, 79% of respondents felt that they knew whom to go to for support with those challenges, for example, GPs or practice managers.

4.6.3 Training received in remote triage

18% of respondents had received training in triage between January 2020 and January 2022. This training could be delivered through: 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).

Different modes of training had different benefits. Formal and informal training face-to-face helped respondents to clarify how to prioritise different needs within resourcing constraints, provided examples of different styles of communication and history-taking, and how to ask the right questions within the limitations of telephone triage. Formalised remote training supported respondents in better understanding the triaging systems’ processes and assumptions.

45% of all clinical respondents reported that they provided training to their colleagues. This training could be formal or informal, ad-hoc or planned. For example providing on-the-job training on-to-one, group training during practice meetings, and providing training to reception on information-gathering. Of respondents that reported training colleagues, 68.1% were either ‘confident’ or ‘very confident’.

In addition to these training routes, 52% of respondents had accessed additional resources to improve their remote triaging skills. These included reading GP Forums, peer-reviewed articles, and other official guidance (e.g. the RCGP video consulting guide). Some respondents also reported accessing other specialised training pathways, such as a targeted webinar on triaging children and a Master’s module in minor illness.

Respondents suggested that training could be improved by protecting time for clinicians to undertake supervised training, ideally face-to-face with case studies/scenarios.

4.6.4 Challenges in remote triage supervision

42% of respondents supervised colleagues who carry out triage (“supervisors”). The majority of these respondents spend, on average, 10 hours or fewer per week carrying out this supervision. Of these supervisors, 55% reported facing challenges when supervising remote triage. Analysis of free-text comments has highlighted common themes of:

• Insufficient time to supervise amidst high workload demands
• Difficulty building juniors’ confidence/skills to manage uncertainty and workloads
• Mistrust of information collected digitally
• Concerns around staff adaptability to new systems
• High trainee staff turnover

65% of respondents stated that there was someone to go to for help if they had difficulties. Named examples included other colleagues, practice managers, clinical leads, and GPs.

4.6.5 Data insights

Only 10% of respondents look at data within the practice to identify variations in triage outcomes between staff. The types of data described by respondents included: daily trends, volumes and triage requests, daily modes of consultation, triage speed and conversion to an face-to-face appointment, patient re-attendance, ‘double-handling’ of patients and adverse outcomes.

4.7 Remote consultations

Within the survey, ‘remote consultations’ were defined as those conducted by phone, video, or written messaging (including SMS or online forms).

4.7.1 Percentage of respondents who do and don’t carry out remote consultations

94% of clinical respondents reported that they carry out remote consultations. Of the 6% of clinicians that did not consult remotely, the majority were practice nurses (33%) and healthcare assistants (21%).

4.7.2 Modalities used to carry out remote consultations

Possible modes of remote consultation included: phone, video, and written messaging (via SMS or online). Across clinical groups, the most commonly used modality is phone, with 50% of all clinical respondents using it for 51% or more of their consultations. Pharmacists reported the heaviest use, with a majority reporting that over 71% of their consultations were carried out by phone. Nearly half of GPs reported that between 51-70% of their consultations were delivered via phone. The second most commonly used modality was written messaging, though the usage was significantly lower than that of phone: 50-60% of clinical staff used messaging for 1-10% of consultations. Video was the least used modality, with 56% of clinical staff that carry our remote consultations reporting never using it. The majority of nurses and pharmacists report no utilisation of video calls. 59% of GPs report 1-10% of their consultations being by video.

4.7.3 Confidence when carrying out remote consultations

Again, staff confidence levels varied across different modes of consultation, and across staff groups, as outlined in Figure 5. The most confident staff group across the remote consultation modalities (written messaging, phone, video) were GPs. All clinical staff reported fairly high levels of confidence in conducting consultations via phone. Nurses (50%) and pharmacists (52%) were not confident using video consultations, and reported not using this mode in their day-to-day practice. A significant minority of GPs (37%), nurses (47%), and pharmacists (48%) report lower confidence in consultations using written messaging

Figure 5: Responses to the question ‘How confident do you feel in using these remote consultation modalities?’

4.7.4 Training received in remote consultations

At the time of the survey, which closed on the 23rd of February 2022, 17% of clinical respondents reported having received training in carrying out telephone consultations since January 2020. 15% of all clinical respondents had received training in carrying out video consultations, and 7% had received training in carrying out consultations via written messaging, despite its reported consistent use by clinicians. While they reported the heaviest use of phone consultations, less than 25% of GPs and pharmacists reported having training in the two years prior to the survey.

60% of respondents stated that there were aspects of carrying out remote consultations that they found challenging. Free-text responses were analysed to highlight the following themes across clinical staff: 

• Literacy and language barriers (use of English, digital literacy).
• Communication issues (body language and non-verbal communication).
• Duplication/inefficiencies (needing more time to complete a remote consultation than a face-to-face consultation, or duplicating effort by having to refer patients for face-to-face appointments after a remote consultation, patients not answering the phone).
• Suitability of remote consultations (for example, clinical examinations that cannot be done remotely and are not appropriate for all patients). 
• Building rapport.

31% of respondents reported providing training (formal or informal, e.g. ad hoc or on-the-job) to colleagues on carrying out remote consultations. This training includes:

• discussion of what communication and assessment skills were required for remote consultations
• discussion of cases where the consultation has been remote
• ad hoc debriefing
• tutorials with trainee GPs
• ongoing support and supervision

The majority of respondents feel confident providing training to colleagues on carrying out remote consultations. However, 24% rated themselves as ‘somewhat confident.’

4.7.5 Supervising colleagues who carry out remote consultations

49% of respondents were responsible for supervising colleagues who carry out remote consultations, and the majority spent 10 hours or fewer per week doing this.

40% of respondents stated that there were aspects of supervising colleagues who carry out remote consultations that they found challenging. Analysis of free-text responses to a question about the most challenging aspects highlighted a lack of time to train and supervise others whilst meeting their own high workloads and difficulties judging the attitudes and abilities of staff under supervision without direct supervision. 

4.7.6 Looking at data within the practice to identify variation in consultation modality and outcomes

7% of respondents look at data within the practice to identify variation in consultation modality and outcomes between staff. The data looked at includes consultation style, effective and appropriate prescribing, rates of conversion from a remote to face-to-face consultation and data from their system provider.

4.8 Training topics chosen by clinical staff

Clinical responders were asked about training topics that interested them across non-clinical and clinical tasks.

4.8.1 Non-clinical training topics

Clinicians reported widespread interest across non-clinical training topics, the most popular being:

• remote communication skills (e.g. 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

4.8.2 Clinical training topics

The distribution of preferences reported by clinicians across the clinical topics was similarly even, as highlighted in Figure 6. The most popular were:

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

Figure 6: Responses to the question ‘What clinical training topics would interest you?’

Although GP interest was consistent across most topics, they showed particular interest in training on remote clinical examinations and in clinical risk management during remote consultations. They were also interested in training to improve demand/capacity understanding and in remote communication skills.

Nurses were also interested in remote clinical examinations, as well risk stratification and remote chronic disease management. Out of all roles, they showed the most interest in training on changes to OC system and technical OC training.

Pharmacists showed interest in clinical risk management during remote consultations and in best practice for remote consultations. They also showed interest in non-clinical training covering changes to OC systems and technical OC training.

When asked about training delivery preferences, the most commonly chosen training options were: live webinars, eLearning, face-to-face training, and pre-recorded videos.

16% of respondents had a preference for who delivered their training. These included Trusted organisations (for example,. the RCGP, specialised hubs or accredited agencies) and experienced trainers, clinicians, and peers. Respondents suggested that training using real-life examples or practical scenarios was particularly helpful.

4.9 Final comments from clinical staff

Respondents were asked for final comments about training to support triage and the use of remote consultations in general practice. Their free-text responses were analysed, and the most common comments foregrounded the need for protected time to engage with training. There were fundamental concerns raised about using remote triage and consultation, specifically around risks for digital exclusion and disadvantages for some patients. There were calls for more support in using IT, managing changes in daily work, and in managing clinical risk remotely.