Understanding the invisible workforce: lessons for general practice from a survey of receptionists

Safety issues in post-discharge care of older patients in general practice: an ethnographic study

BACKGROUND

Post-inpatient discharge is a risky time for older patients, especially those with polypharmacy and multimorbidity. General practice care at this time, including the processes for managing hospital discharge summaries, lacks standardisation and is of variable quality. Understanding these processes will support the design of interventions and guidance to improve general practice management of the post-discharge period.

AIM

To understand and visualise how ongoing care for older people after discharge from hospital is organised in general practice, including the processes for managing discharge summaries.

DESIGN AND SETTING

Rapid ethnography study in 10 general practices in the West Midlands, England.

METHOD

We mapped the practices' systems of post-discharge care. Data sources included informal conversations with staff, practice policies, and direct observations of discharge summary handling. Fieldnotes and quotes were subject to an interpretivist framework analysis. A systems modelling technique (the Functional Resonance Analysis Method) was used to present visual representations of the professional roles working in these complex systems.

RESULTS

Three basic typographies of system emerged based on professional roles: GP-led, pharmacist-led, and administrative-led. We report on three themes that weave around the Functional Resonance Analysis Method process maps: comfort with demands of administrative role; general practice team dynamics; and interaction with patients.

CONCLUSION

General practice systems for inpatient discharge summary processing are complex and varied. New roles in general practices are being used extensively, often requiring significant input in supervision by GPs. Our findings highlight safety features of different systems and should help practices understand the advantages and limitations of models they work within.

Impact of the COVID-19 pandemic on medical office assistants (MOAs) working in primary care: a qualitative study

BACKGROUND

Medical office assistants (MOAs), also known as receptionists and clerks, are frontline workers and the most accessible member of the primary care team. Historically, their contributions to primary care have been unrecognised and undervalued. The COVID-19 pandemic put pressure on existing roles and systems in primary care: how MOAs adapted is unknown.

AIM

To explore the experiences of MOAs working in primary care during the COVID-19 pandemic from the perspectives of MOAs and family physicians (FPs) who worked with MOAs during this period.

DESIGN & SETTING

A qualitative study, using constructivist grounded theory (CGT), was conducted in Ontario, Canada.

METHOD

Seventeen participants were recruited through professional contacts of the research team. Individual semi-structured interviews were undertaken with MOAs and FPs across the province.

RESULTS

MOAs' many responsibilities in primary care intensified during the pandemic. MOAs leveraged their healthcare system knowledge and therapeutic relationships with patients to reduce patient distress. Unfortunately, MOAs experienced more frustration, and in some cases, abuse from patients. MOAs' ability to adapt to new systems and respond to high patient needs seemed to be positively influenced by their relationships with patients and FPs. FPs showed support for MOA welfare and recognised their critical role on primary care teams.

CONCLUSION

MOAs made considerable contributions to primary care during the COVID-19 pandemic. This study suggests MOAs have greater capacity than previously recognised, which has important implications for planning in an era of under-resourced health care.

Impact of the clinically oriented roles of a general practice receptionist: a systematic review with narrative synthesis

BACKGROUND

Modern general practice is characterised by increased demand and growing multidisciplinarity, including ring-fenced funding for additional non-clinical roles. For practice receptionists, however, training has remained unchanged for decades despite primary care being under greater pressure than ever, with receptionists becoming a growing focal point for abuse and unprecedented numbers leaving the role.

AIM

To present the evidence of the range of tasks that receptionists continue to perform, describing their impact on primary care delivery and how the role might be better supported.

DESIGN AND SETTING

Systematic review of research conducted in the UK.

METHOD

A systematic review of evidence contained in the major medical databases (MEDLINE/PubMed, CINAHL, ASSIA, Cochrane Library, and Embase) from January 2000 to March 2024 was conducted, including hand searches of the bibliographies of included studies.

RESULTS

In total, 29 studies were identified that grouped into three themes: service delivery, patient attitudes, and receptionist experience. The theme 'service delivery' confirms the continuing role of receptionists in providing administrative support alongside the clinical tasks of prioritising patients for consultations, facilitating repeat prescriptions, and communicating blood test results. The theme 'patient attitudes' describes how patients lacked trust in receptionists, who were viewed as unqualified and unnecessarily obstructive. Finally, in considering receptionist experience, the contrast between their confidence in performing administrative roles and the anxiety induced from the clinically related tasks was described, particularly the mounting pressure from patients to meet their preferences for clinician appointments.

CONCLUSION

Although confident performing administrative tasks, receptionists described uncertainty and anxiety when providing clinically oriented support or managing patients when their requests for appointments could not be met. More appropriate training or professionalisation might improve staff retainment.

Enhancing access to primary care is critical to the future of an equitable health service: using process visualisation to understand the impact of national policy in the UK

Access to UK general practice is complicated by the need to provide equitable and universal care within a system adapting to workforce challenges, digital innovation, and unprecedented demand. Despite the importance of accessing primary care in meeting the overall aim of delivering equitable care, this is the first time the direct and indirect influence of policies intended to facilitate access have been systematically explored. Further consideration by policymakers is needed to accommodate the difference between what patients need and what patients want when accessing primary care, and the differences in their ability to utilise digital options. The designation of care was hindered by long-standing issues of reliable data and variations in the interpretation of local and national protocols and guidelines.

The Impact and Wider Implications of Remote Consultations for General Practice in Norway: Qualitative Study Among Norwegian Contract General Practitioners

BACKGROUND

The digital shift toward remote consultations in general practice needs ongoing monitoring to understand its impact on general practice organizations and the wider health care system.

OBJECTIVE

This study aimed to explore how remote consultations impact on contracted general practitioner (GP) practices and how GPs perceive the implications of this uptake for the overall health care system.

METHODS

In total, 5 focus groups were conducted with a total of 18 GPs from all 4 health regions of Norway in 2022. The material was subjected to Braun and Clarke's thematic analysis.

RESULTS

The analysis yielded six themes: (1) the design of novel effective clinical pathways: remote consultations empower GPs to tailor new effective clinical trajectories, blending modalities to address diverse needs across clinical episodes-from initial triage, through investigations to case closure; (2) increased workday flexibility: remote consultations introduce variability into daily work, allowing GPs to adjust patient contact intensity, and leading to a less stressful work-home balance; (3) erosion of organizational boundaries: easy remote access to GPs appears to reduce patients' tolerance for minor illness and self-care, hindering effective gatekeeping and shifting GPs' focus from proactive to more reactive work, increasing work-related stress; (4) degradation of clinical shrewdness: confronted with an increasing amount of unsorted and trivial remote inquiries, GPs observe challenges in detecting and prioritizing serious cases; (5) dilemmas related to responsibility, ethics, and legislation: remote consultations highlight a tension for contract GPs between legal responsibilities and ethical obligations, with implications for patients with limited health literacy; this may entail suboptimal evaluation or delayed treatment-potentially contributing to increased health care inequity; and (6) retaining clinical core values in a changing world. Overall, GPs affirm that remote consultations have come to stay and describe efforts to effectively manage the advantages and disadvantages inherent in such interactions to safeguard clinical effectiveness and organizational sustainability of primary health care.

CONCLUSIONS

The widespread adoption of remote consultations in the Norwegian contract GP scheme fundamentally reshapes the dynamics of GP work and the overall health care system. Awareness and proactive management of these changes are essential for maintaining sustainable, high-quality primary health care.

Revealing administrative staff roles in primary care during the COVID-19 pandemic: a qualitative study of family physicians' perspectives

Background

Administrative staff in primary care undertake numerous tasks to support patient care delivery. Although their roles are often overlooked, administrative staff are essential to the coordination and operations of primary care clinics. The COVID-19 pandemic introduced additional clinical and administrative tasks, including transitioning to virtual appointments and triaging patients for urgency, changing typical workflows. In Canada, existing pandemic plans for primary care did not account for these administrative tasks, nor the support that family physicians would require to continue to provide patient access to primary care. This research seeks to describe and understand the perceptions and experiences of family physicians of their administrative staff roles in primary care during the COVID-19 pandemic, to help inform future pandemic planning.

Methods

We present findings from a qualitative case study across four regions in Canada: Vancouver Coastal health region in British Columbia, Ontario Health West region, the province of Nova Scotia, and the Eastern Health region of Newfoundland and Labrador. We conducted semi-structured qualitative interviews with family physicians (n = 68) across the four regions and thematically analysed the data.

Results

We identified five salient themes in the data, including (1) applying public health guidelines, (2) educating patients on COVID-19 and COVID-19 services, (3) re-organizing patient visits, (4) maintaining adequate staffing, and (5) recognizing administrative staff contributions. During the COVID-19 pandemic, family physicians took on numerous additional roles to reduce the risk of transmission of the virus with the support of their administrative staff. Family physicians emphasized the challenges of maintaining adequate staffing, and the importance of administrative staff in enabling the provision of primary care.

Conclusions

Existing pandemic plans do not account for increased administrative roles taken on by primary care administrative staff. Pandemic plans must include guidance for the roles taken on by primary care administrative staff, such as clinical tasks, as they will continue to play an important role in pandemic recovery. Supporting administrative staff would enhance primary care providers' ability to manage care during pandemics, facilitate resilience, and decrease provider and administrative burnout.

The Doctors, Their Patients, and the Symptom Checker App: Qualitative Interview Study With General Practitioners in Germany

BACKGROUND

Symptom checkers are designed for laypeople and promise to provide a preliminary diagnosis, a sense of urgency, and a suggested course of action.

OBJECTIVE

We used the international symptom checker app (SCA) Ada App as an example to answer the following question: How do general practitioners (GPs) experience the SCA in relation to the macro, meso, and micro level of their daily work, and how does this interact with work-related psychosocial resources and demands?

METHODS

We conducted 8 semistructured interviews with GPs in Germany between December 2020 and February 2022. We analyzed the data using the integrative basic method, an interpretative-reconstructive method, to identify core themes and modes of thematization.

RESULTS

Although most GPs in this study were open to digitization in health care and their practice, only one was familiar with the SCA. GPs considered the SCA as part of the "unorganized stage" of patients' searching about their conditions. Some preferred it to popular search engines. They considered it relevant to their work as soon as the SCA would influence patients' decisions to see a doctor. Some wanted to see the results of the SCA in advance in order to decide on the patient's next steps. GPs described the diagnostic process as guided by shared decision-making, with the GP taking the lead and the patient deciding. They saw diagnosis as an act of making sense of data, which the SCA would not be able to do, despite the huge amounts of data.

CONCLUSIONS

GPs took a techno-pragmatic view of SCA. They operate in a health care system of increasing scarcity. They saw the SCA as a potential work-related resource if it helped them to reduce administrative tasks and unnecessary patient contacts. The SCA was seen as a potential work-related demand if it increased workload, for example, if it increased patients' anxiety, was too risk-averse, or made patients more insistent on their own opinions.

The changing shape of English general practice: a retrospective longitudinal study using national datasets describing trends in organisational structure, workforce and recorded appointments

OBJECTIVE

To describe trends in the organisational structure, workforce and recorded appointments by role in English general practice.

DESIGN

Retrospective longitudinal study.

SETTING

English general practice.

DATA SOURCES AND PARTICIPANTS

NHS England, Office for Health Improvement and Disparities and Care Quality Commission national administrative datasets covering between 5 to 10 years from 2013 to 2023.

RESULTS

Between 2013 and 2023, the number of general practices fell by 20% from 8044 to 6419; the average practice list size increase by 40% from 6967 to 9724 patients. The total population covered by providers with over 100 000 registered patients reached 2.3 million in 2023 compared to 0.5 million in 2017. The proportion of practices under individual ownership decreased from 13% to 11% between 2018 and 2023; there was little change in the proportion owned by partnerships, incorporated companies or NHS bodies, which respectively averaged around 80.3%, 6.9% and 0.7%. Between 2015 and 2022, there was a 20% rise in the total full-time equivalent (FTE) general practice workforce, including Primary Care Network staff, from 1.97 to 2.37 per 1000 patients because of an increase in multidisciplinary other 'Direct Patient Care' (DPC) and administrative roles. The number of nurses remained stable, and the number of qualified general practitioners (GPs) decreased by 15%. In September 2022, there were 0.45 FTE qualified GPs per 1000 patients; GPs and other DPC roles, excluding nurses, each represented 19% of the FTE per 1000 patients workforce; administrative roles represented 51%. The general practice workforce is predominantly female. A quarter of GPs qualified overseas. Between 2018 and 2023, there was no clear upward or downward trend in total appointments per 1000 patients with, on average, half provided by GPs.

CONCLUSIONS

Since 2013, there has been a shift in general practice towards larger practices with more multidisciplinary teams, alongside a reduction in the number of FTE qualified GPs per 1000 patients. We recommend that the impacts of these changes on access, quality and costs are closely monitored.

Client and employee engagement measures predict resignations of veterinary support staff: An analysis of UK companion animal practice data

BACKGROUND

This study aimed to identify factors associated with veterinary support staff resigning from UK companion animal veterinary practices.

METHODS

Cross-sectional employment data from support staff working across a group of veterinary practices on 31 December 2020 were retrospectively analysed. The support staff were categorised as those who remained at, or resigned from, their practice over the following 12-month period. The proposed risk factors for future resignations were analysed using multivariable binary logistic regression modelling.

RESULTS

In total, 398 of 2068 (19.2%) veterinary support staff resigned during the study period. Factors associated with greater odds of future resignations included lower staff engagement (employee net promoter score; odds ratio [OR] = 0.99; 95% confidence interval [CI] 0.99-1.00; p < 0.001), lower client practice engagement (net promoter score; OR = 0.98; 95% CI 0.97-1.00; p = 0.012), shorter tenure (OR = 0.92; 95% CI 0.90-0.95; p < 0.001), recent parental leave (OR = 2.37; 95% CI 1.38-4.07; p = 0.002) and younger age (OR = 0.99; 95% CI 0.98-1.00; p = 0.017).

LIMITATIONS

Data were collected retrospectively and were not recorded for research purposes.

CONCLUSIONS

Employee and client net promoter scores are important predictors of resignations and could be useful tools for managers. Recent parental leave is a predictor of support staff attrition, and 'return to work' interventions may present an opportunity to improve retention.

Beyond empathy training for practitioners: Cultivating empathic healthcare systems and leadership

Empathic care benefits patients and practitioners, and empathy training for practitioners can enhance empathy. However, practitioners do not operate in a vacuum. For empathy to thrive, healthcare consultations must be situated in a nurturing milieu, guided by empathic, compassionate leaders. Empathy will be suppressed, or even reversed if practitioners are burned out and working in an unpleasant, under-resourced environment with increasingly poorly served and dissatisfied patients. Efforts to enhance empathy must therefore go beyond training practitioners to address system-level factors that foster empathy. These include patient education, cultivating empathic leadership, customer service training for reception staff, valuing cleaning and all ancillary staff, creating healing spaces, and using appropriate, efficiency saving technology to reduce the administrative burden on healthcare practitioners. We divide these elements into environmental factors, organisational factors, job factors, and individual characteristics.

A Bibliometric Analysis of Telephone Triage Research to 2021 Using VOSviewer

Telephone triage services are becoming increasingly commonplace in modern healthcare. Despite this widespread adoption, health researchers and practitioners seeking to understand evidence-based best practice face several challenges. Firstly, the few systematic reviews available yield small sample sizes, suggesting a small amount of research. Secondly, the rapid pace of development of telephone triage technologies means that there may be temporal validity issues with the available research, given some of this research is relatively old. Thirdly, researchers use different terminologies to describe telephone triage, meaning evidence may be more difficult to find than if consistent terminology was used. This bibliometric analysis therefore is aimed at providing a macroscopic overview of telephone triage, to understand the scale and scope of the available evidence (i.e., where, when, and by whom research is conducted), for interested researchers and practitioners. Additionally, it is aimed at quantifying the prevalence of terms used to describe telephone triage, to recommend consistent terminology for future use, and to improve accessibility of research. To address these aims, literature searches using three different key terms: "telephone triage," "remote triage," and "teletriage" were conducted in Scopus and PubMed. Corresponding bibliometric data was visualised and analysed using VOSviewer. This bibliometric review identified 784 papers since the term "telephone triage" first appears in 1980, confirming a paucity of literature in the field. An overview of telephone triage research up to 2021 is provided, which should serve as a useful foundation for future research and application of evidence-based practice. Gaps in telephone triage research are identified, and the use of consistent terminology is encouraged, with the aim of supporting telephone triage researchers in determining research priorities and improving the impact of future studies.

"You're only a receptionist, what do you want to know for?": Street-level bureaucracy on the front line of primary care in the United Kingdom

Introduction

In care settings across the globe non-clinical staff are involved in filtering patients to the most appropriate source of care. This includes primary care where general practice receptionists are key in facilitating access to individual surgeries and the wider National Health Service. Despite the complexity and significance of their role little is known of how the decision-making behaviors of receptionists impact policy implementation and service delivery. By combining the agent-based implementation theory of street-level bureaucracy with a tri-level analytical framework this work acknowledges the impact of the decisions made by receptionists as street-level bureaucrats and demonstrates the benefits of using the novel framework to provide practical insight of the factors influencing those decisions.

Methods

A secondary analysis of qualitative data gathered from a series of semi-structured interviews conducted with 19 receptionists in the United Kingdom in 2019 was used to populate a tri-level framework: the micro-level relates to influences on decision making acting at an individual level, the meso-level influences at group and organizational levels, and the macro-level influences at a societal or policy level.

Results

At the micro-level we determined how receptionists are influenced by the level of rapport developed with patients and would use common sense to interpret urgency. At the meso-level, influences included their position at the forefront of premises, the culture of the workplace, and the processes and protocols used by their practice. At the macro-level, participants described the impact of limited health service capacity, the lack of mandatory training, and the growth in the use of digital technologies.

Conclusions

Street-level bureaucracy, complemented with a tri-level contextual analysis, is a useful theoretical framework to understand how health workers, such as receptionists, attempt to provide universality without sufficient resource, and could potentially be applied to other kinds of public service workers in this way. This theoretical framework also benefits from being an accessible foundation on which to base practice and policy changes.