Article Figures & Data
Figures
- Figure 1. Themes from the patient survey and staff focus groups and synthesis of findings
Tables
- Table 1. Characteristics of the 22 general practices recruited to the panel, by practice size
Practice sizea n Region of England, n Setting, n National deprivation quintile, n Ethnicity, n Percentage of patients aged ≥65 years, n PMS or APMS contract (versus GMS), nb Prior research activity, n North Middle South Urban or sub-urban Inner city Rural 1 and 2 (least) 3 and 4 5 and 6 7 and 8 9 and 10 (most) >10% of patients non-White <15% 15.0%–19.9% 20.0%–24.9% ≥25% <2500 3 3 0 0 1 0 2 0 2 0 1 0 0 0 0 2 1 1 0 2500–4999 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5000–7499 5 2 1 2 3 1 1 1 1 1 0 2 3 1 1 1 2 3 3 7500–9999 6 4 1 1 4 2 0 1 1 2 1 1 0 1 5 0 0 4 1 10 000–14 999 2 1 0 1 2 0 0 1 0 0 0 1 0 0 1 0 1 1 2 ≥15 000 6 2 2 2 4 1 1 1 1 2 2 0 0 3 2 1 0 1 0 Total 22 12 4 6 14 4 4 4 5 5 4 4 3 5 9 4 4 10 6 aNational mean practice size in May 2022 = 9522 registered patients.47 bThe General Medical Services contract is the standard contract between practices and NHS England. Some practices voluntarily agree to a local contract, Personal Medical Services, or Alternative Personal Medical Services. APMS = Alternative Provider Medical Services. GMS = General Medical Services. PMS = Personal Medical Services.
- Table 2. Patient survey distribution, response rates, and experiences of access across 21 practices
Category Median Mean SD Minimum Maximum 25th percentile 75th percentile Survey distribution and response rate across 21 practices Percentage of patients aged ≥18 years on practice list as willing to receive text messages from practice 87.9 84.4 14.4 32.5 99.4 80.1 91.7 Percentage of text messages sent that were delivered 92.0 91.5 5.3 76.6 100.0 90.1 94.1 Response rate as percentage of text messages delivered 10.9 13.4 6.9 3.8 32.5 9.7 14.6 Patient reported experiences across 21 practices Percentage reporting fairly or very easy to get appointmenta 47.8 48.5 24.7 16.3 98.0 29.4 62.1 Percentage reporting fairly or very easy to get through on the phonea 66.2 60.7 26.5 15.6 99.4 35.2 82.0 Percentage reporting fairly or very good experience of the practicea 74.0 71.0 17.8 42.9 98.3 55.8 84.3 Percentage thinking staff at their practice definitely or probably work well as a team 88.0 83.7 12.7 57.3 99.4 74.4 93.5 aItems taken from the annual national General Practice Patient Survey. SD = standard deviation.
- Table 3. Analysis of 10 348 comments from 8408 patients in 21 practices participating in the patient survey
Category Mean, %a SD Median, %a Minimum, %a Maximum, %a Number of comments per practice 492.8 284.9 405 148 1202 Proportion of comments per practice that were: Positive 51.2 23.8 49.9 19.1 98.8 Negative 41.8 22.6 40.6 1.2 74.9 Mixed positive and negative 7.0 3.6 7.0 0.0 12.4 Proportion of all comments in a practice that were regarding Theme 1: Contact and access (n = 3256 comments, 31.5%) 28.8 11.3 28.7 8.8 47.2 Proportion of theme 1 (contact and access) comments that were: Positive 22.5 29.7 10.3 1.3 96.9 Negative 74.8 30.1 87.3 3.1 97.6 Mixed positive and negative 2.8 2.4 2.2 0.0 8.3 Theme 2: Attitude, approach, interaction (n = 4761 comments, 46.0%) 49.4 12.6 47.0 33.4 78.2 Proportion of theme 2 (attitude, approach, interaction) comments that were: Positive 74.3 16.4 75.2 40.7 99.5 Negative 16.8 12.1 14.8 0.5 45.1 Mixed positive and negative 8.9 5.6 8.4 0.0 22.0 Theme 3: Healthcare processes, provision (n = 1925 comments, 18.6%) 18.0 4.5 17.5 11.9 28.7 Proportion of theme 3 (healthcare processes, provision) comments that were: Positive 49.4 25.3 53.6 9.6 100 Negative 38.9 24.7 33.1 0.0 84.6 Mixed positive and negative 11.7 6.8 11.2 0.0 27.2 Theme 4: Expressions of failure (n = 232 comments, 2.2%) 2.1 1.6 1.6 0.0 5.1 Theme 5: Extreme adverse situations (n = 174 comments, 1.7%) 1.7 0.9 1.4 0.0 3.6 aUnless otherwise stated.
Perspective Quote Comments Patient theme 1: Contact options and availability: the practicalities of access 4.1 ‘Dissatisfied with the telephone appointments last week on [telephone] for 4 hours and 15 minutes before l got through to reception and then told no telephone appointments left it's really bad after being on the phone for so long and told to ring again tomorrow.’ (P1A p38)
‘... the thought of trying to battle through the system to get an appointment means I will just put up with any ailments.’ (P10 p2)4.2 ‘It takes far too long to make an appointment on the phone. The appointments are too far in the future ... econsult form invariably tells me to go to A and E when this is not necessary. I think the system is broken.’ (P14 p11) 4.3 ‘It is very frustrating that if I want to book an appointment that isn’t urgent, I can’t get an appointment for weeks. So I end up doing an on the day urgent appointment, which makes me feel guilty.’ (P12 p5) 4.4 ‘Very difficult to get a face-to-face appointment when necessary. It took 2 months ... from initial econsult, then a phone call appointment before the doctor agreed to see me. A recent phone appointment occurred out of the guide time so I missed it. No apparent understanding that patients might be working ... trying to keep well ... do not have all day to wait for a phone call or text.’ (P10 p27) 4.5 ‘The website content is convoluted, cluttered, repetitious and overlapping. Not user friendly ... I often have to ring ... for clarification after sifting through the website ... [Once] I was given very misguided advice/information ... a result of lack of understanding on the reception part ... more phone calls ... ended up with an appointment with the surgery that should have been with [an] optometrist. So much wasted time and resources.’ (P7 p8) 4.6 ‘Trying to do anything online is complex — website sends you down rabbit holes and round in circles. Difficult to get through on the phone.’ (P10 p20) 4.7 ‘... [askmyGP] massively improved the experience of seeking help ... ”opening hours“ for online services [have been] heavily reduced ... varying day by day with no guarantee that it will be open ... they ”reach capacity” for online queries early in the day and then it’s back to queuing on the phone for 30 minutes plus to speak to reception, which may be completely unnecessary.’ (P9 p14) 4.8 ‘It is impossible to get through to talk to anyone. The response time can be as long as 30 people before me. The Econsult is no longer available. I have asked for appointments with a doctor for both myself and my husband ... Cancer patient, 3 heart attacks, Covid ... A physician’s assistant responds to my requests for advice from a doctor and promises prescriptions and responses from specialist clinicians which never arrive or arrive 3–4 weeks later. I am not happy with the service and would move to another practice but have heard similar stories about alternatives.’ (P1A p49) 4.9 ‘I only phone when I need to speak to a doctor, and I find they [reception] take control and tell you you can’t, very unhappy you can’t see a doctor!!!!!!!!’ (P16 p11) 4.10 ‘... you first have to negotiate the receptionist ... they are the brick wall you have to negotiate. I’m told you need to give them the information to direct you to the best person. The best person is MY own doctor who would know my needs and not see a different person every time!’ (P10 p42) 4.11 ‘Too hard to speak with actual doctors. Telephone receptionists asking too personal questions on why you are calling and then being unhelpful if you would rather not say for personal reasons.’ (P10 p27) Staff theme 2: Patient interactions: communication and impact 4.12 ‘It’s not that we’re preferring it ... They don’t have to come here. And some of them think they can get things dealt with on the phone that can’t be dealt with.’ (GP3/P1 L199-204) 4.13 ‘For us, e-consults have just exploded, so we’ve now taken two of the receptionists totally off reception and they’re now care coordinators, and they deal with all the e-consults.’ (A1 /P4 L390-391) 4.14 ‘... at first, it was brilliant, obviously, through COVID and everything. We’ve found it’s getting more and more difficult, and we’re just overrun at the minute.’ (A1/P1 L365–366) 4.15 ‘We’d hit capacity by ten past nine ... it takes three of us [admin] just to manage that ... We don’t distribute appointments. Everything goes through ... askmyGP ... Even when it’s turned off, they’re ringing up ... they want to be dealt with today ... we think now they’re using us as a first port of call rather than a chemist, ‘cos they can just send a picture … ‘ (A1/P1 L365-378) 4.16 ‘... two of the receptionists totally off reception and they’re now care coordinators ... so signpost patients elsewhere rather than the GP practice ... But the phones are still massively busy.’ (A1/P4 L390-394) 4.17 ‘... there were just so many unnecessary consultations that were face to face previously that were basically a patient want rather than a patient need, and we can filter those out in far less time now and manage that in a much more sort of proactive way.’ (GP2/P8 L318–320) 4.18 ‘... people who are really, you know, IT savvy ... They don’t want to put their information on a website where anyone can see it. They don’t want to tell the receptionist what the problem is. [Citing a recent call] ... “I am not telling a doctor what is wrong with me on the telephone. I want an appointment. I want my bum on a seat.”’ (PM1/P5 L215-223) 4.19 ‘... the majority of the phone calls after we’ve turned off, no matter what it is, we find that people have been a lot less patient ... — they want dealing with now.’ (A1/P1 L675-680) 4.20 ‘... we put it in, like many others, quite quickly because of covid and it worked brilliantly ... trying to get out of the system ... is now incredibly hard. We’ve spent weeks and weeks trying to put a new appointment system in place, and changing over e-consult to now be only same-day assessment ... to bring back contacting the surgery directly, ‘cos now we’re getting the face to face and telephones back at the moment.’ (A1/P2 L418-428) 4.21 ‘... a year and a half training patients how to use e-consult, which was difficult, and now it’s going to take that long again to train them to the new way we want ... patients are frustrated and finding it extremely confusing, and actually so are we. So, what was brilliant for one point in time has now become a bit of a conflict in our surgery.’ (A1/P2 L418-428) Patient theme abbreviations: P = practice number; and p = page number. Staff theme abbreviations: as 2–3 groups were provided for each staff category, numerals beside the following three abbreviations indicate the focus group number for that staff category: A = administrative and reception staff; N = nurse; and PM = practice manager. Remaining staff theme abbreviations: L = line number in transcript. P = participant.
- Table 5. Patient and staff perspectives on overlapping theme 2: non-clinical roles and patient care
Perspective Quote Comments Patient theme 3: Clinical care and treatment: process and provision 5.1 ‘The receptionist seem to think they are the doctor and want to know why I need to see or want to speak to the doctor even if the doctor has asked me to call back ... ’ (P16 p6) 5.2 ‘Very much dislike system of having to request a call from GP by explaining problem to receptionist. They are not qualified to triage and it is another hurdle to actually seeing the doctor. First you have to call, then get call back, then arrange an appointment.’ (P8 p6) 5.3 ‘I didn’t feel comfortable [about] questions asked by receptionist who is not in my opinion medically competent to judge if I needed a face to face consultation or call back by GP.’ (P16 p7) 5.4 ‘Receptionists often provide medical ”advice” and judgements (as they ask the reason for appointments) that they are no way qualified to give.’ (P16 p27) 5.5 ‘... you don't want to have to speak to the doctor about your problem with your colleagues listening. Also I don't want to talk to the receptionist about my problems. All these hurdles have made me delay booking an appointment about something I need to see the doctor about.’ (P8 p6) Staff theme 1: Roles and responsibilities: confidence and competence 5.6 ‘... GPs don’t make a lot of decisions ... The only thing they decide is if they’re bringing a patient in face to face ... where the appointments go and how they get made is all left up to the admin and the one receptionist ... [when available] appointments are finished, the e-consult slots are full, but people are still ringing ... it’s left up to the admin team to decide what’s urgent enough to go on the on-call list.’ (A1/P7 637-642) 5.7 ‘... It gets very difficult to feel like you’re doing what you’ve signed up for here, ‘cos sometimes you feel like you’re a brick wall before the GP and not necessarily the door into the GP. I’ve had patients say to me on the phone, “Why am I being triaged by you to see the doctor when all I want to do is see the doctor?” And I want to say to them, “I don’t want to do it, I don’t want to do it, but this is just how it works.”’ (A1/P7 650-654) 5.8 ‘... we have a bit of a turnover in reception, but I would have thought it would be greater for the amount — they get so little benefit in comparison with the amount of hassle and abuse ... ‘ (PM1/P8 L845–847) 5.9 ‘... nurse practitioners used to do our triage before covid hit and askmyGP came onto the scene ... far better, to be honest, for patients ... askmyGP has a receptionist that’s in charge of directing all requests ... And that can cause a muddle sometimes because they’re unsure who to direct things to, whereas when you had a practitioner doing your triage, it was directed far more effectively. [Facilitator: And do you think that will go back ... ?] Well, a couple of the GPs would prefer to, but then others wouldn’t, and so it depends really on who your GP is as to whatever. So, at the minute, no, it isn’t going to go back.’ (N1/P5 L692-697) 5.10 ‘They [non-clinical staff] are starting to read the messages and the information that’s given to them more, which has improved things, and I think calmed the partners down a bit as well. ‘Cos the duty doctor always leaves their door open and listens to what’s going on, and then they come to me saying, “How many questions did that person ask today? Why don’t they know this? And why don’t they know that?” they’re stressing everybody out.’ (PM2/P1 L421-425) 5.11 ’... we started like an online consult thing, that then the admin team deal with rather than reception. And the communication between the admin team and the GPs, it’s not great, because we’re having to work in so many different ways depending on which GP it is. Some of them want things doing one way. Some of them want things doing another way, which then can cause friction back to reception, because if reception have taken a phone call that’s been passed on to us for a GP but it’s not got certain information that one doctor would want and one wouldn’t ... ‘ (A1/P1 L270-278) Patient theme abbreviations: P = practice number; and p = page number. Staff theme abbreviations: as 2–3 groups were provided for each staff category, numerals beside the following three abbreviations indicate the focus group number for that staff category: A = administrative and reception staff; N = nurse; and PM = practice manager. Remaining staff theme abbreviations: L = line number in transcript. P = participant.
Supplementary Data
- HG_10.3399BJGPO.2025.0069_v2.pdf -
Supplementary material is not copyedited or typeset, and is published as supplied by the author(s). The author(s) retain(s) responsibility for its accuracy.
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English general practice in a period of change: a mixed-methods study of staff and patient perspectives
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