Foreword and Executive Summary

Foreword

Primary care remains at the heart of our communities, being the first port of call for advice and support in the NHS for over a million people a day. General Practice is the bedrock of the NHS. However, it is managing approximately 15% more demand than it was pre-pandemic. There are fewer General Practitioners (GPs) providing care for greater numbers of patients – on average practices are managing 17% more patients than they were 8 years ago. This trend is predicted to continue; the number of people aged over 85 is estimated to grow by 55% by 2037 and the age of onset of major ill health has not changed.

This growing need and complexity of care will put further pressure on our already stretched primary and community care services. If the NHS is to continue to be a world-beating health service, we need to invest in recruitment, retention and development of our workforce alongside enabling a model that better supports general practice to be fairer, safer and more sustainable.

The Delivery Plan for Recovering Access to Primary Care sets out the ambition for Modern General Practice and identifies data and digital technologies as key components of the effort to enable more equitable, inclusive and personalised care. A model which moves away from a first come, first served approach to one which prioritises care based on need; ensures multi-modal access to avoid a ‘one-size fits all’ approach; gathers better understanding of need at the point of contact to allow a more personalised approach; and optimises use of our multi-professional expertise.

Most practices are already doing some or all of these elements. However, by consistently bringing them together and making them as robust as possible, we can realise the biggest cumulative impact. Training, capability building and providing support and time for our workforce to manage change, are central to this ambition. So too is improving patients’ understanding through consistent and effective communication.

Research shows practices that have transformed their model in these ways have higher levels of patient satisfaction, better staff experience, improved access and continuity of care. In my practice, for example, located within a very deprived area, we have found benefits in identifying urgent and serious clinical need more quickly, and improving equity of care. As a result of changes we’ve made to the ways we work, whether patients contact us by phone, online or in person, it’s easier to direct them to the most appropriate health care professional and type of appointment – offering greater flexibility for them and our practice team, more opportunities to provide continuity of care, improved efficiency and less duplication of tasks.

This approach underpins the National General Practice Improvement Programme. The programme team work alongside great general practice teams across the country to build up and codify knowledge, share collective learning and provide hands-on improvement support, capability-building and training. We help practice and Primary Care Network (PCN) teams to make changes more easily and sustainably, realise the greatest benefits as quickly as possible and build the confidence, capacity and skills needed for leading ongoing improvement. Shared and active learning is at the heart of the support provided, underpinned by local and national peer communities.

The programme seeks to ensure digital technology enhances the benefits for both patients and staff. It includes significant user research to develop evidence-based improvements in digital tools, to ensure they are easy for patients and practice teams to use and provide the right functionality.

The programme works alongside wider system support, including public communications, expansion of community pharmacy services, nationally funded training, and increased funding for digital tools and new ways of working.

As the research described in this report shows, investment in developing and supporting general practice teams is key to ensuring we have the right skills, tools and support in place to be able to deliver the care people need now and in the future.

Dr Minal Bakhai MBE

Director for Primary Care Transformation

General Practitioner

Executive summary

Background to the research

In January 2019 the NHS Long Term Plan stated that every patient would be offered the right to access primary care digitally by 2023/24 (NHS, 2019). When restrictions were introduced by the government in March 2020 to limit the spread of COVID-19, practices were urged to implement a ‘total triage’ approach supported by the use of online systems, and to deliver consultations remotely (via video, phone, or digital messaging) where clinically appropriate (NHS England and NHS Improvement, 2020). This situation greatly increased the speed at which practices adopted the use of online consultation systems. The 2023/24 General Medical Services contract required that all ‘directly bookable’ appointments be available online, and considered the use of remote consultations (by telephone, video or written messaging) as part of the standard offer across practices (NHS England, 2023). The recent NHS Access Recovery Plan sets out the ambition for a Modern General Practice Access Model and identifies digital technologies as a key component of the effort to enable a fairer, safer, more sustainable model of general practice (NHS England, 2023).

The research project described in this report was developed in 2019 with the aim of undertaking discovery research to support the NHS Digital Academy team at NHS England and the Primary Care Transformation Team at NHS England to develop digital training offers for general practice staff. The focus was on the skills needed for both clinical and non-clinical staff to safely and confidently use online consultation and triage solutions effectively, given that these skills are foundational to the new model of general practice.

Aims and methods of the research

The key questions the research aimed to answer were:

• What training offers currently exist for front-line general practice staff to support them in using online consultation and triage systems effectively?
• How effective are existing training offers considered to be by general practice staff?
• What are the training needs of general practice staff? In what specific areas would they like to receive training?
• How should training be delivered?

The research was carried out in 2 phases. Phase 1 was qualitative, involving focus groups and interviews, and was run between May 25, 2021, and July 15, 2021. Phase 2 was a quantitative survey developed using the findings of Phase 1 and was live between January 18, 2022, and February 23, 2022.

Findings

Findings focus on the results of Phase 2 but are informed and supported by insights from Phase 1.

Training between January 2020 and January 2022 for non-clinical and clinical staff

Whilst instances of peer-learning were reported frequently, general practice staff received limited formal training in gathering patient information, triage, and remote consultations between January 2020 and January 2022.

• 34% of non-clinical staff received training in gathering patient information and navigating patient requests, while 66% did not receive any such training; this is despite 68% reporting that this is part of their role.
• 18% of clinical staff received training in carrying out triage.
• 17% of clinical staff received training carrying telephone consultations.
• 15% had received training in carrying out video consultations.
• 7% had received training in carrying out consultations via written message.

The amount of time clinical and non-clinical staff spent on training and study between January 2021 and January 2022 was generally low, with over 50% of respondents completing 20 hours or fewer and 20% completing more than 50 hours. Specifically, most non-clinical staff received under 20 hours of training, while the distribution of clinical staff across hours trained was more varied. The effectiveness of the training that was provided was undermined by staff capacity limits; a majority of participants experienced barriers to completing training or study. When asked to identify the “top 5” barriers to training, the 3 most commonly selected across clinical and non-clinical roles (791 total) were:

• high workload: selected by 74% of respondents
• lack of protected training or study time: selected by 38% of respondents
• training times clashing with practice meetings or other practice or PCN priorities: selected by 34% of respondents

Summary of staff training needs and preferences

Across staff groups, the results of the quantitative and qualitative phases of this project strongly indicate that staff in general practice are working in new ways and that this has created a distinct need (and staff buy-in) for additional training in associated skills.

At the time of the survey (January 2022), 70% of non-clinical staff reported that their daily work included gathering patient information or navigating patient requests. Yet, 65% of non-clinical staff had not received formal training in this task between January 2020 and January 2022. Within that, 35% of the reception staff respondents reported that they had been working in general practice for less than 2 years and had received no training in gathering patient information and navigating patient requests. In relation to this, some non-clinical respondents reported low levels of confidence in signposting patients to services outside the GP surgery (30%), approximately 25% in explaining new access routes and processes to patients, and in identifying patients who need a face-to-face appointment (22%).

The majority (64.5%) of clinical staff reported that their daily work included triage – within this a much higher proportion of GPs (89%) reported being responsible for triage compared to nurses (42%). 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 in remote consultations and choosing the correct consultation mode (phone, video, or written messaging). A significant minority of GPs (37%), nurses (47%), and pharmacists (48%) report lower confidence in consultations using written messaging. This is a notable training need due to 50-60% of clinical staff reporting that they used messaging for 1-10% of their consultations. Clinical respondents felt most confident about identifying red flags and issues that require urgent medical attention.

When asked about their clinical areas of interest, clinical survey respondents reported being most interested in training on remote clinical assessment and examination and managing clinical risk in remote consultation. The qualitative phase indicated that developing skills in assessment and communication during online consultations was also important to this group.

Non-clinical staff were most interested in training on identifying red flags, supporting patients who struggle to use technology, and learning how to use data and quality improvement methods to understand demand and capacity, and effectively use technology.

The quantitative phase indicated that, across staff groups, there was consensus on the central barriers to training and preferences in modes of training delivery. Barriers included high workload, lack of protected time, and de-prioritisation of training. The most commonly chosen delivery modes across groups were: eLearning modules, face-to-face training, and live webinars. Respondents generally found training useful when it was practical, with real-life examples, tailored to their role and practice, with different avenues for additional information.

Discussion

Whilst the local picture of particular configurations of hardware, software, and modalities for remote triage and consulting vary across individual practices across the NHS, it is widely agreed that the daily work of general practice staff has fundamentally changed. New digital technologies and modalities necessitate a diversity of training to learn their functions, processes, and best uses in practice workflows. They also change the kinds of work different staff groups conduct, which creates further training in explaining new access routes to patients (patient navigation), gathering patient information and routing patient requests, remote consulting skills, communication skills in remote consulting modalities, and remote risk management. Whilst training rates had been low during the period of study (January 2020 – January 2022), staff across roles reported that they had engaged in peer learning and learning on-the-job and valued the insights and support of more senior colleagues whilst doing so.

Survey respondents across all roles indicated their top 3 preferences for training delivery to be eLearning module, face-to-face training, and live webinar. Other training modes that were commonly selected include pre-recorded videos and written guidance. In qualitative discussions, participants highlighted the value of hands-on, practical training with peer support and mentorship as an effective form of training; this was particularly referring to training for development of complex skills, such as communication skills. Observation and the ability to ask questions were also considered valuable. Participants further commented that it was important for training time to be properly ringfenced and regularly updated and refreshed to allow for changes in processes and to maintain confidence and skill.