Abstract
Background The COVID-19 pandemic prompted widespread use of remote (telephone and online) communication in general practice in England, which exacerbated long-term pressures from staffing shortages. The public perceived problems with access.
Aim To explore patient and staff perspectives on changing processes in general practice.
Design & setting A mixed-methods study (patient survey and staff focus groups) in a sample of 22 general practices in England, varied by size, region, deprivation, and demography, was conducted in 2022.
Method An online survey was delivered by short message service (SMS) text to adult patients at 21 practices. Data from answers to an open-ended question about patients’ experiences were analysed using summative content and thematic analysis. Virtual focus groups conducted with four categories of staff (GPs, nurses, receptionists and administrators, and practice managers) covered teamworking, roles, patient interactions, adapting to change, and workload. Data were transcribed and analysed using framework and thematic methods. Themes common to patients and staff were identified.
Results Overall median survey response was 10.9% (interquartile range 9.7%–14.6%); 14 401 patient responders provided 10 348 comments, 51.2% were positive. Patient and staff perspectives overlapped in two areas. The first, ‘contact and communication’, encapsulated differing views around access. The second, ‘non-clinical roles and patient care’, concerned the allocation of appointments and the roles of receptionists. Patients reported barriers to getting timely appointments with their chosen professional while staff were seeking ways to manage the volume of communications. Use of non-clinical staff to triage appointment requests was unpopular with patients and receptionists felt clinically unqualified.
Conclusion Effective methods are needed to improve patient communication with practices and access. Receptionists require recognition and training for their pivotal role.
How this fits in
Pressures in general practices in England owing to rising demand and staff shortages were exacerbated by the COVID-19 pandemic. This investigation of patient and staff experiences in a varied sample of general practices in 2022 found two key areas of overlapping concern around patient access and receptionists’ roles. Solutions are required to persisting problems around access: patients report problems contacting practices and getting appointments to meet their needs, while staff report being overwhelmed by the ‘explosion’ of electronic communication. Non-clinical staff are increasingly taking on triage roles, which is unpopular with patients, and receptionists feel unqualified for this task.
Introduction
Access and the debate about providing care remotely are central to concerns about the sustainability of general practice in England.1 For many years before the COVID-19 pandemic, demographic, systemic, and societal pressures that were threatening the patient experience had been building.2 Demand had increased owing to an ageing population with complex health and care challenges. Rising patient expectations and the transfer of tasks from hospitals to community settings added to the workload in general practice, and staff recruitment and retention had become serious problems.3,4 The situation was exacerbated in March 2020 when the UK government, in response to COVID-19, triggered abrupt changes in service delivery by instructing general practices to conduct consultations remotely (telephone and online) whenever possible.5–7 New systems resulted in the emergence of ‘modern’ receptionists. The traditional role of receptionists of issuing doctor appointments and liaising on home visits has transitioned into managing multidisciplinary options and flagging up alternatives to patients, including by remote contact. Receptionists may also be charged with triaging patient requests for consultations with the aim of optimising resources.8 The public, however, perceived serious problems with access.9–11 Concerns were raised about the safety of care delivered remotely and confidence in consultations declined.6,12–15
Various initiatives to address the workforce crisis (for example, technology, extended use of mid-level practitioners, and shared funding for additional roles such as physiotherapists and physicians’ associates) required practices to constantly reassess and adjust ways of working. Patients faced uncertainties around accessing care, and staff sought a manageable workload.16 This study draws on data from two elements of a larger study exploring patient and staff perspectives on changing processes in general practice (National Institute for Health and Care Research [NIHR] Health and Social Care Delivery Research Programme, project number: 17/08/34). Themes common to both patients and staff were triangulated to inform practices, policies, and future research.
Method
Design and setting
A sample of general practices was recruited. Information was distributed to practices across England by NIHR Clinical Research Network (now Research Delivery Network) regional offices. Expressions of interest were received from 72 practices. Data on these practices were compiled in a spreadsheet (region, number of registered patients for practice size, age distribution of patients, deprivation (Index of Multiple Deprivation) decile, urban or rural, and workforce characteristics), then 25 were purposively selected to provide maximum variability and invited to participate. Of these, 22 agreed. Practices were each reimbursed £500 on completion of data collection.
Data and analysis
Data comprised patients’ responses to an open-ended question (within a larger survey) and staff views expressed in focus groups. Data collection, preparation, and analyses were carried out independently for the patients’ responses and focus groups, before examination of findings for overlapping themes. Data were anonymised. A service-user panel of 12 members (patients and public) worked with the research team on refining the data collection instruments, coding framework, and the interpretation of findings.
Patient survey
The patient survey was set up in Qualtrics. Between February and May 2022 study information and survey links were distributed by practices to registered adult patients who had signed up to receive text messages. The survey comprised 22 structured questions about access and experience of the practice, and brief background information about the responder (age, gender, last use of practice, and employment status). An optional open-ended question stated: ‘The space below is for a short comment or notes you would like to add to describe your experiences of the practice, such as, for example: — helpful, interested, friendly, understanding, kind; — unhelpful, not interested, irritable, always too busy’ (maximum 300 words) (see Supplementary Information S1).
One practice did not use text messaging to communicate with patients and did not participate. Responses from the remaining practices on the survey platform were exported to Microsoft Word files. Summative content analysis was used to analyse responses to the open-ended question.17,18 Two researchers (AH and BJ) analysed the data using annotation and colour-coding on paper copy. They discussed the generation of codes and definitions, comparing notes and agreeing criteria. The approach was discussed frequently, including with a third researcher (HG) as analysis progressed. Initial reading assessed length, detail, and variability of content. Patient comments were relatively simplistic in terms of length and use of language, so coding was semantic, attributing straightforward definition to unambiguous statements. Individual data were not sufficiently in-depth or comprehensive to facilitate an interpretive approach. Codes were drawn from the data of five practices and refined so that comments could be rated as positive or negative. Data from the remaining practices were then coded. Where individual responses covered multiple comments, each comment was coded and rated separately. A framework reflecting different categories of issues (or potential themes) was generated and this was reviewed and refined. Positive, negative, and mixed (positive and negative on the same issue) codes were counted across all data, and by category, and for individual practices, and proportions calculated. The categories were described in narrative form. Patient Participation Groups at participating practices were invited to review and comment on findings for their practice.
Focus groups
Focus groups for staff were convened between December 2021 and March 2022. Separate discussions were conducted for four staff categories: GPs; nurses; administrative and reception staff; and practice managers. Owing to the ongoing pandemic, groups were conducted virtually on Microsoft Teams. Full information was distributed to practices with a request to find volunteers among staff. Informed consent was provided before participation. Discussions lasted a maximum of 90 minutes and were audio-recorded and transcribed verbatim; synchronous ‘chat’ comments were retrieved. Topics covered included the following: teamworking; interactions with colleagues and patients; changing roles; workload; and job satisfaction. Group discussion was the preferred method of data collection because it enabled participants to explore and clarify views through the group process.19 Basing groups around key categories of staff provided a degree of homogeneity and equality.20
Focus groups, data processing, and framework analysis were undertaken by SB, AB, RCa, CM, EM, and KS. Data were coded using a framework developed by the research team and bounded by the research aims. Additional inductive thematic analysis was carried out within the framework by BJ and AH. Transcripts were annotated by hand using an iterative and reflexive process of semantic coding, clustering, and attributing themes.21 Further details can be found in Supplementary Information S2.
Synthesis
Findings from separate analyses of patient and staff data were considered in parallel, looking for overlapping themes. Data sources were triangulated to provide a more comprehensive understanding of common topics from patients’ and staff perspectives.
Results
Practice characteristics
The sample of 22 practices was largely representative of the national distribution of practices by size. Defining features of some practices included high deprivation and high proportions of older or younger (student) patients (Table 1). Practice staff numbers ranged from 7 to 109; most had a core team of GPs, nurses, administrative and reception staff, and managers; one practice was nurse-led with locum GPs. Two of the smallest practices had opted not to join other local practices in a primary care network (PCN), which would have given access to some additional shared health professional resources; five practices were part of a super practice comprising an entire PCN. In the most recent Care Quality Commission inspections, 20 practices had scored good and two were deemed outstanding; none were reported as requiring improvement or inadequate. In the 2021 national General Practice Patient Survey, the proportion of patients reporting a very or fairly good experience of their practice ranged from 61%–100%.
Patient survey
A total of 14 401 responses were received. The overall median response rate (from text messages delivered) was 10.9% (mean 13.4%, interquartile range 9.7%–14.6%) (Table 2). Most responses were from women (n = 8866 [61.6%]; n = 5369 [37.3%] men; n = 36 [0.2%] other gender identity; and n = 130 [0.9%] missing); 13 195 (91.6%) identified as White British. Around one-third were in full-time employment (n = 5078, 35.3%) and 4225 (29.3%) were aged ≥65 years; nearly two-thirds had been in contact with the practice in the previous 6 months (n = 9284, 64.5%). Reporting at practice level of a good experience varied considerably, ranging from 42.9%–98.3% (Table 2).
Some participants did not answer the open-ended question; others offered several comments. Overall, 8408 (58.4%) participants provided a total of 10 348 comments (average 1.23 comments per person). The proportion of participants providing any comment was relatively even across practices (mean 58.8%, standard deviation [SD] 4.5%, median 59.8%, range 46.1%–66.5%). The lowest proportions were in the two most deprived practices. Those most likely to provide comments were women (61.4% versus 53.1% of others); people aged ≥65 years (68.2% versus 52.6% in younger groups); people without parenting responsibilities (60.1% versus 50.1% of parents or guardians of children aged <16 years); carers of others with long-term physical or mental health conditions, disability, or old age problems (64.0% versus 56.7% without); and people not in full-time employment (62.7% versus 50.6% of those working full-time) (χ2 P<0.001 for each comparison).
Considering all 10 348 comments, just over one-half (51.2%) were positive, about two-fifths (41.8%) were negative, and the rest were mixed, with considerable variability among practices (Table 3). The highest proportions of positive comments (85.8%, 98.1%, and 98.8%) were from the three smallest practices, each with <2000 patients; these practices also had the highest response rates (32.5%, 27.8%, and 16.7%). Practices with the largest proportions of negative comments were in urban or city areas with highest deprivation and ethnic populations. Older people offered significantly more positive comments (n = 8280 comments, Spearman rho -0.015, P<0.001), while parents, carers, and people in full-time employment offered more negative ones (all Mann–Whitney U P<0.001).
Five themes were attributed to the data. There was variation among practices in the distribution of comments by theme (Table 3). Theme 1 (31.5% of all comments) covered contact with and access to the practice; across all practices, this theme had the highest proportion of negative comments. Theme 2 (46.0%) related to non-medical aspects, specifically staff attitudes and engagement culture; around three-quarters (74.3%) of these comments were positive remarks about staff. Theme 3 (18.6%) related to the processes and provision of clinical care and issues around consultations. The role of non-clinical reception staff undertaking triage to decide what health professional and type of appointment could be offered surfaced as an issue of widespread concern in this theme. The final two themes (<4%) captured grievances against the practice: expressions of failure where responders were considering leaving the practice or going elsewhere (for example, privately) because they could not get the care they wanted in a timely manner, and extreme accounts of misdiagnosis or wrong treatments. Themes 4 and 5 were combined with theme 3 in a revised three-theme framework (Figure 1).
Staff views
A total of 38 staff volunteered for focus groups from 18 practices. Nine focus groups took place: two with nurses (n = 7); two with administrative and reception staff (n = 11); two with practice managers (n = 12); and three with GPs (n = 8). Groups were small owing to challenges of staff availability and scheduling.
The initial coding framework (see Supplementary Table S1) helped define three themes (Figure 1). The first related to team structures and teamworking covering roles and responsibilities, professional boundaries, and staff shortages. Teams within teams were identified by nursing and administrative and reception staff; participants from smaller practices and GPs and managers tended to identify with the whole practice. Issues were raised around responsibility for patient triage in most groups. Changes in colleague communication methods since the pandemic were described. WhatsApp groups were widely used and useful although issues around blurring of formal and informal messaging and the overwhelming amount of communication generated were expressed. The importance of face-to-face interactions and value of daily ‘huddles’ or coffee breaks with colleagues was acknowledged.
The second theme focused on the interface with patients and managing the ‘explosion’ of electronic communication after the pandemic. Staff recognised patients’ frustrations with access and expressed concerns that patient care would be jeopardised by increasing workloads. The third theme related to maintaining staff wellbeing in the changing, pressured work environment. Staff discussed wellbeing measures at their practices, including group yoga, lunchtime walks, and staff parties.
Synthesis
Triangulating data from the patient surveys and staff focus groups identified two overlapping themes. The first, ‘contact and communication’, encapsulated different perspectives on accessing general practice (patient theme 1 and staff theme 2). The second, ‘non-clinical roles and patient care’, derived from feedback from both groups on the processes involved in the allocation of appointments (patient theme 3) and the roles and responsibilities of non-clinical staff (staff theme 1; Figure 1). These overlapping themes are presented below, with supporting comments in Tables 4 and 5.
Overlapping theme 1: contact and communication
Patients’ descriptions covered functional aspects of access via telephone or online as well as availability of timely, suitable appointments. While some responders liked the convenience of telephone consultations, frustration was reported owing to queuing, being cut off, and too few same-day appointments that were all allocated soon after lines opened. The time, cost, and stress of making repeated calls deterred some participants who said they lived with problems rather than ‘battle through’ to make an appointment (quote 4.1). Patients from some practices took issue with time frames for non-urgent appointments that could involve a wait of 3–6 weeks (quote 4.2). Participants admitted to exaggerating the urgency of a problem to avoid waiting (quote 4.3). Getting an appointment was a particular issue for people in full-time employment who found it difficult to make or take personal calls during working hours. Frustrations were expressed when a telephone appointment with a doctor was missed because it was not made at the pre-arranged time (quote 4.4).
Comments highlighted individual differences in the acceptability of online engagement. Some criticised poorly designed websites that hindered access (quotes 4.5 and 4.6), while others who found online systems convenient were annoyed when the service was reduced (quote 4.7). Practice policy of offering appointments with an alternative practitioner when consultation with a GP was requested was an issue for many (quote 4.8). Many regarded receptionist and care navigator roles as a barrier to access (quotes 4.9, 4.10, and 4.11).
Staff described telephone or the online ‘askmyGP’ service as core ways for patients to contact practices; many consultations were also remote, by telephone or video link. While online communication with patients was described as largely successful and necessary, accounts revealed challenges from the process, technology, and workload, including task duplication, for example, when inadequate telephone consultations required face-to-face appointments (quote 4.12). Staff reported that patients used online contact to the extent that ‘e-consults have just exploded’ (quote 4.13) and it was ‘getting more and more difficult, and we’re just overrun’ (quote 4.14). Even though online services were sometimes temporarily closed as practices became overwhelmed, the workload was still unmanageable, with insufficient slots for appointments (quote 4.15). Staff acknowledged that congestion was a barrier to patient access even when patients could be steered to alternative sources of support (quote 4.16).
The clash between patient requests to see a GP and practice policies of diverting, where appropriate, to non-medical colleagues, was described as negotiating ‘a patient want rather than a patient need’ (quote 4.17). Ability to triage incoming requests and steer patients away from the practice to other sources of support (such as pharmacists) was seen as an efficient way of handling high levels of demand. Staff were sympathetic, however, to patient resistance to the triage system that requires them to divulge personal information online or to reception staff on the telephone, or in the reception area where they could be overheard (quote 4.18).
Staff recognised that the system of engaging with patients was fraught with hitches and expressed understanding of patients’ problems getting through on the telephone. Staff were overwhelmed and patients disappointed, frustrated, and less tolerant when they were unable to log on (quote 4.19). One practice was trying to reinstate direct contact while retaining online access (quote 4.20) but the process seemed to have rendered patients as objects, ‘to train them to the new way we want’ (quote 4.21).
Overlapping theme 2: non-clinical roles and patient care
Patients’ concerns about the processes and provision of clinical care and treatment covered many issues, including: loss of face-to-face appointments with GPs; lack of confidence in telephone diagnoses; limited time in consultations; missed health checks; non-communication of test results; and lack of continuity with the same GP. Most prominent, however, was the role of non-clinical staff and especially being asked by receptionists for personal information. Receptionists were regarded as neither qualified nor trained for carrying out triage and deciding whether a problem should be referred to a doctor (quotes 5.1, 5.2, 5.3, and 5.4). Participants did not anticipate having to voice personal details when they telephoned practices, so they were not necessarily in a private place (quote 5.5).
Discussions with staff covered receptionists’ roles and responsibilities, and reflected patients’ concerns about triage by non-clinical staff. Issues were raised around unwanted change in responsibility, inadequate training, competence, low confidence, and abusive behaviour from frustrated patients (quotes 5.6 and 5.7). There was awareness that changes in responsibilities deviated from original job specifications and several indications that they had been imposed. While there seemed to be overall agreement that the ‘hassle and abuse’ (quote 5.8) non-clinical staff received from some patients was unacceptable, comments mirrored patients’ perspectives that patient-facing staff were a barrier to access. There was an impression of administrative and reception staff ‘in uproar’, but clinicians were also aware of the problems related to non-clinical triage, with indications of concern from some (quotes 5.9 and 5.10). The process could be hindered by poor internal communication (quote 5.11).
Discussion
Summary
The study recruited practices of varying sizes serving differing populations across England 2 years after the onset of the global pandemic triggered the swift adoption of remote communication and consultations with patients. While overall around half of all comments from patients were positive (higher in three small practices), key issues reported by patients were difficulties contacting practices and getting appointments at a time, and with the professional of their choice, and concerns about the gatekeeping function of receptionists and their role in patient triage.
The challenges faced by patients in contacting practices for appointments were acknowledged by staff, along with concerns about communication with patients. Staff described being overwhelmed by the volume of patient communications, online as well as by telephone, but did not offer solutions or effective strategies. Comments indicated that patients were not considered as active contributors in practice processes, but were seen as needing training in understanding and complying with new methods.
There were concerns about functional aspects of non-clinical staff roles in all staff focus groups. Patients were unhappy about non-clinical staff processing medical information, while receptionists expressed fears about their competence in dealing with clinical details. Just as patients were frustrated by changes imposed on them, reception staff were unhappy about changes to their roles, made without consultation and with minimal, or no, training.
Strengths and limitations
This study uncovers and explores issues from the perspectives of service users and providers. However, it has some limitations. Data collection was carried out within 6 months of the end of the second national COVID-19 lockdown when practices were still in a phase of adjustment, and this may have hindered recruitment of practices. Despite this, the objective to include at least 20 varied practices was met.
Patient participation was limited to those with smartphones and sufficiently familiar with technology to engage with a survey link sent by text message. The option for requesting a paper copy received only one request. Therefore, people with lower incomes, disabilities, or poor literary skills are likely to have been excluded. The survey was available only in English, therefore language issues may have prevented some from participating. Targeted outreach within practices to enable digitally excluded or non-English speaking patients to express their views was not feasible because of continuing restrictions after the pandemic. Patient perspectives obtained through the survey are based on responses to only one optional question. This was a pragmatic decision recognising the need to keep the questionnaire brief and simple to encourage responses. Response rates were low and some bias was observed with women, older people, parents, carers, and those not in full-time employment more likely to respond. Participants might have disproportionately been people with strong opinions, especially problems and concerns with the service or their care; non-responders may be those with a neutral view, lack of familiarity with the practice, or too busy. We sought confirmation from Patient Participation Groups as to whether responses were representative of the practice situation. Although it is now a statutory requirement for practices to have an active Patient Participation Group, some practices had not reconvened their groups after suspending them during the COVID-19 pandemic; those groups that were active indicated the comments of participants were valid. Several also described ongoing changes in their practices to mitigate problems that the survey had identified.
The recruitment of practice staff to focus groups was challenging owing to the COVID-19 winter wave of illness. Four practices offered no volunteers; six practices participated only in one focus group. Holding focus groups with staff online provided flexibility but some groups had small numbers of participants because staff could not attend at the last minute. It was particularly difficult to recruit GPs. Finding a private space was a challenge for some participants, meaning that there were occasional interruptions. Despite these challenges, important insights, experiences, and opinions were shared.
Comparison with existing literature
Improving access to general practice has been a policy priority for many years.22 Access is a multi-component concept23 and many different approaches have been trialled.24,25 Recent research shows that rules and processes intent on improving access may exacerbate problems, particularly continuity of care26,27 and finding privacy in remote consultations,28 both issues raised by our participants. Consistent with our finding of patient dissatisfaction with telephone access, the annual national General Practice Patient Survey reported only 50% of responders stating it was fairly or very easy to get through to someone on the phone at their practice in 2023, a fall from 81% in 2012.29 In line with our results, evidence from patients and staff show mixed views about online tools. While some perceive convenience benefits, others are concerned that some patients are disadvantaged and that problems may be missed or treatment delayed.30 Digital work also creates technostress, technosuffering, and relational strain among staff.31 A big data analysis, however, argues that an online general practice access model using digital and non-digital pathways with triage can effectively manage patient-initiated demand, remain sensitive to patient preferences, prioritise care, and optimise workforce use, although implementation needs to reflect local context and requires support.32
Tasking receptionists with triaging functions has been identified as both a potential safety issue and inefficient since inappropriate decisions can result in multiple appointments instead of one face-to-face encounter.14 Participants in our study confirmed this finding and the conclusions of another recent study in which receptionists described their role as ambiguous and inadequately understood and recognised, and highlighted inadequate training for the clinically relevant aspects of their revised jobs.8 Patient dissatisfaction when receptionists cannot provide an appointment at a convenient time or with a preferred GP is a long-standing problem33 and sometimes results in aggression towards receptionists.34–36 This was noted in some focus groups and points to the need for special training and workplace measures to protect the wellbeing of reception staff.36 Early ethnographic research identified the influence of personal judgement and power, and issues of variability, subjectivity, inconsistency, and potential inequality in the receptionist role,37 and this was also apparent in our findings. A recent systematic review also confirmed our analysis of the overlap between the views of receptionists and patients, namely that receptionists are anxious about clinically oriented tasks, such as triage, while patients lack trust in receptionists and view them as obstructive and unqualified.38
Implications for research and practice
The pandemic accelerated changes across general practice that were already evolving. The shift from a demand-driven service designed to meet patients’ requirements and in-person appointments to one limited by capacity14 and offering remote access has created a complex process of service delivery that staff and patients in many practices are learning to work with. Service users in small practices (<2000 patients) were highly positive and reported minimal access problems suggesting a need to explore the effect of practice size and organisation. Others, for example, have suggested that staff working in micro-teams or ‘teamlets’ might improve communication with patients, working environments, coordination, and continuity of care.39–42 For over a decade practices have been encouraged to work at scale to the detriment of continuity of care and the patient experience.43 In addition, as part of NHS England’s plans for a digital transformation of the NHS, practices must now put processes in place to ensure equitable access for people who might otherwise have difficulty seeking or benefiting from care, such as those who cannot afford a smartphone, have no internet, are disabled, or have poor literary skills.44
The pivotal role of receptionists in enabling access for patients and acting as gatekeepers to GPs and other health professionals45 merits further research. The role is recognised as challenging with emotional impact (‘emotional labour’) resulting from engaging with conflicting priorities and providing empathy.33 It is also influenced by factors largely outside the control of receptionists such as workplace culture, processes and protocols, digital technologies, and limited health service capacity.46
Receptionists require support to navigate the challenges of their role, training, and a career path that recognises its centrality for effective service delivery.8 Establishing a professional code of practice for receptionists, as exists for clinicians, would help define role boundaries, provide a basis for shared understanding across all staff groups, and enable patients to feel more secure in the triage process. This could be underpinned by a recognised training programme that goes beyond in-practice induction to cover issues such as dealing with sensitive information and difficult patients. Further research on frontline relationships in primary care is required to inform this. Training for all staff roles is required to facilitate effective engagement with patients. Systems need to be both efficient and patient friendly. Involving patients in decision making around practice processes is important for taking account of their preferences, improving understanding of constraints practices face, and offering ownership of adjustments that are implemented. While Patient Participation Groups are intended for such involvement, a practice champion could coordinate activity and ensure effective group function.
Notes
Funding
This project was funded by the NIHR Health and Social Care Delivery Research Programme (project number: 17/08/34). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Ethical approval
The survey and focus groups were part of the wider ‘GP Teams’ project (NIHR project number: 17/08/34), which received a favourable ethical opinion from the North of Scotland Research Ethics Service (RES) (Integrated Research Application System project: 256757; RES reference: 19/NS/0188), and from the NHS Health Research Authority and Health and Care Research Wales in January 2020.
Provenance
Freely submitted; externally peer reviewed.
Data
The dataset relied on in this article is available from the corresponding author on reasonable request.
Acknowledgements
We thank the National Institute for Health and Care Research (NIHR) Clinical Research Network (CRN) Kent, Surrey, and Sussex for support as the lead CRN for the GP Teams project, and all regional CRNs for assistance with recruiting general practices. We are grateful to the GP Team’s Service User Panel, led by Phelim Brady, for providing an independent perspective on the work, and for advice from the project’s Panel of Professionals and Commissioners and External Steering Committee. We thank two reviewers for their helpful feedback on an earlier version that led to significant improvements in the article.
Competing interests
The authors declare that no competing interests exist.
- Received March 30, 2025.
- Revision received June 10, 2025.
- Accepted June 25, 2025.
- Copyright © 2026, The Authors
This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)
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