Simon Bailey

The recently published NHS 10 Year Health Plan¹ envisages an NHS built around ‘neighbourhood health services’, with a significant rebalancing of investment and spending away from hospitals to services delivered in local communities. The plan is clear that each area will be free to develop its own service model, but a number of elements are highlighted as being important. These include:

Objectives Access to general practice in England is a challenging issue of enduring importance. COVID-19 precipitated various abrupt changes, exposing and compounding existing problems. The access as human fit conceptualisation provides a nuanced understanding of access that extends beyond a limited focus on appointment numbers and speed. This qualitative study explored the pandemic’s impact on access to general practice and the experiences of patients and healthcare staff in England using access as human fit as an analytical framework. Design A community-based participatory approach underpinned by qualitative semi-structured interviews and focus groups, and observations. Setting and participants The following were conducted in Northwest England (December 2021—August 2022): interviews (10 participants) with patients, general practice staff and professionals; seven focus groups (42 participants) with patients from general practice patient groups and underserved groups; and twenty observation sessions of non-clinical access encounters (seven general practice and Primary Care Network premises; 45 hours total). Analysis A rapid qualitative analysis methodology facilitated an abductive thematic approach, applying the dimensions of access as human fit to the data. Results The access as human fit framework highlighted key areas where there is a lack of fit between patients and staff. Patients expressed that the array of access options and changes made it hard to know how to be a patient; some thought general practice should be ‘back to normal’ and the pandemic was an excuse to restrict access. Providers reported working harder than ever with insufficient resources. Conclusions The pandemic created greater distance between staff and patient realities of access. Access as a human fit facilitated in-depth exploration of patient and staff experiences, improving understanding and identifying key issues. Broader adoption and application of this framework, within policy and practice, could focus improvement efforts, optimise access fit and improve patient satisfaction and staff retention.

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.

The figure of a dragon-like and unsympathetic receptionist primarily focused upon keeping patients out of practices² remains sadly prevalent,¹ despite research going back decades highlighting the complex realities underlying the trope,³ and the experience of practice staff of increasing abuse as they sit on the front line of an access crisis.⁴ Against this backdrop, Ban et al’s¹ review is timely. They found that, despite receptionists operating as key members of the practice team, with the potential for a significant impact on both patient experience and safety,^5,6 they continue to operate without adequate recognition or training. They highlight the extent to which reception roles involve clinical decision making, without either training or support for this aspect of their role.

Background: Social prescribing programmes across the United Kingdom were obliged to adapt and change as a result of COVID‐19. However, as we emerge from the pandemic and only now begin to witness the extent to which service users and providers continue to be affected, is it realistic to expect social prescribing services to meet the increasing demands placed upon them? How might schemes manage to deliver effectively against a backlog of referrals, escalating mental health issues and growing health inequalities across the population? This paper explores the challenges faced by service providers and service users of social prescribing programmes during the global pandemic. Drawing from primary and secondary research, the discussion considers how the implementation of one social prescribing programme was impacted by COVID‐19, how service providers responded, how service users were affected and, finally, what questions have been raised for the development and delivery of social prescribing in a postpandemic landscape. Methods: Using the reach, effectiveness, adoption, implementation and maintenance (RE‐AIM) framework, this discrete qualitative case study sits within the wider evaluation of Community Connect, London Borough of Bexley’s social prescribing programme. To investigate the impacts upon the programme through the key domains of implementation, maintenance and effectiveness, data were collected between April 2020 and November 2022. One reflexive discussion group and 26 semistructured interviews were conducted with a purposive sample of stakeholders, including social prescribers ( n = 6), service users ( n = 12), service provider organisations ( n = 6), volunteer telephone befrienders ( n = 6) and service commissioners ( n = 2). Framework analysis was subsequently used to code and analyse the resulting qualitative data. Results: Following a period of programme interruption, Community Connect adapted to remote delivery in support of both existing and new service users. Service users experiencing multimorbidity, combined with mental health problems, loneliness and isolation were adversely affected physically, emotionally and socially. Volunteers likewise reported feelings of isolation and uselessness, motivating them to support those in need. An interim ‘telephone befriending’ intervention engendered feelings of self‐worth and reduced social isolation, having a positive impact on mental wellbeing. However, social prescribers experienced challenges in working from home, while attempting to build relationships with new referrals and/or providing meaningful support to digitally excluded individuals. Limited capacity meant many service users experienced intermittent contact with social prescribers, while few were offered consistent support in managing worsening health and/or mental health conditions. In addition, restricted access to voluntary service provider organisations adversely affected all areas of the programme. Those living in deprived circumstances and/or with complex health needs experienced negative impacts upon their long‐term conditions, housing or finances. Many service users now report finding themselves in an escalating state of crisis, while Community Connect and all linked services attempt to address the continuing challenges resulting from COVID‐19 and the current economic crisis. Conclusions: Social prescribing offered valuable support to certain individuals during the first phase of the pandemic but remote contact had limited impact for service users with complex health and/or social needs. Continuing and increasing pressures placed upon social prescribing and voluntary services have resulted in negative outcomes. Findings highlight the vulnerability of social prescribing’s implementation and efficacy when voluntary service organisations and other linked services are disrupted by unforeseen global events.

Introduction In low- and middle-income countries (LMICs), the persistent lack of access and high inappropriate use of antibiotics, which are fuelled by gender-related factors, continue to facilitate antimicrobial resistance. This in turn reduces the capacity to treat infectious diseases. However, there is a lack of clarity on the nature and extent of the available evidence on gender influence on access to antibiotics and antibiotic use behaviour. This proposed study will systematically review the available literature to map out the scope of evidence on gender differences and, importantly, the related factors influencing antibiotic use and access to antibiotics in LMICs. Methods and analysis This scoping review will be conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping reviews. Major databases (MEDLINE, PsycINFO and CINAHL) will be searched via the EBCOhost and Web of Science platforms for peer-reviewed articles. Title and abstract screening, as well as full paper review, will be conducted by a single reviewer, with 20% of identified citations reviewed independently by two other reviewers. A predefined excel spreadsheet will be used for data extraction and analysis. Findings will be presented thematically in a narrative summary and tables. Ethics and dissemination Obtaining ethics approval is not required for this study. The findings will contribute to understanding gender health inequalities and areas for further research on strategies to incorporate gender considerations in antimicrobial stewardship efforts in LMICs. The study findings will be disseminated through presentations in seminars, scientific conferences and publications in peer-reviewed journals.

Background: Significant health inequalities exist in England. Primary care networks (PCNs), comprised of GP practices, were introduced in England in 2019 with funding linked to membership. PCNs have been tasked with tackling health inequalities.Aim: To consider how the design and introduction of PCNs might influence their ability to tackle health inequalities.Design and setting: A sequential mixed-methods study of PCNs in England.Method: Linear regression of annual PCN-allocated funding per workload-weighted patient on income deprivation score from 2019–2023 was used. Qualitative interviews and observations of PCNs and PCN staff were undertaken across seven PCN sites in England (July 2020–March 2022).Results: Across 1243 networks in 2019–2020, a 10% higher level of income deprivation resulted in £0.31 (95% confidence interval [CI] = £0.25 to £0.37), 4.50%, less funding per weighted patient. In 2022–2023, the same difference in deprivation resulted in £0.16 (95% CI = £0.11 to £0.21), 0.60%, more funding. Qualitative interviews highlighted that, although there were requirements for PCNs to tackle health inequalities, the policy design, and PCN internal relationships and maturity, shaped and sometimes restricted how PCNs approached this task locally.Conclusion: Allocated PCN funding has become more pro-poor over time, suggesting that the need to account for deprivation within funding models is understood by policymakers. The following additional approaches have been highlighted that could support PCNs to tackle inequalities: better management support; encouragement and support to redistribute funding internally to support practices serving more deprived populations; and greater specificity in service requirements.

Background: The Additional Roles Reimbursement Scheme (ARRS) provides funding to Primary Care Networks (PCNs) in England to recruit additional staff into specified roles. The intention was to support general practice by recruiting an extra 26 000 staff by 2024, increasing access and easing workload pressures.Aim: To explore the establishment of the ARRS as part of PCNs’ development to understand their role in supporting general practice.Design and setting: A longitudinal, qualitative case study involving seven geographically dispersed PCNs across England.Method: Data were collected from July 2020 to March 2022, including 91 semi-structured interviews and 87 h of meeting observations. Transcripts were analysed using the framework approach.Results: Implementation of the ARRS was variable across the study sites, but most shared similar experiences and concerns. The COVID-19 pandemic had a significant impact on the introduction of the new roles, and significant variability was found in modes of employment. Cross-cutting issues included: the need for additional space to accommodate new staff; the inflexibility of aspects of the scheme, including reinvestment of unspent funds; and the need for support and oversight of employed staff. Perceived benefits of the ARRS include improved patient care and the potential to save GP time.Conclusion: The findings suggest the ARRS has potential to fulfil its objective of supporting and improving access to general practice. However, attention to operational requirements including appropriate funding, estates, and management of staff is important if this is to be realised, as is clarity for the scheme post-contract end in 2024.

Objectives This study aimed to evaluate primary care networks (PCNs) in the English National Health Service. We ask: How are PCNs constituted to meet their defined goals? What factors can be discerned as affecting their ability to deliver benefits to the community, the network as a whole and individual members? What outcomes or outputs are associated with PCNs so far? We draw policy lessons for PCN design and oversight, and consider the utility of the chosen evaluative framework. Design and setting Qualitative case studies in seven PCN in England, chosen for maximum variety around geography, rurality and population deprivation. Study took place between May 2019 and December 2022. Participants PCN members, staff employed in additional roles and local managers. Ninety-one semistructured interviews and approximately 87 hours of observations were undertaken remotely. Interview transcripts and observational field notes were analysed together using a framework approach. Initial codes were derived from our evaluation framework, with inductive coding of new concepts during the analysis. Results PCNs have been successfully established across England, with considerable variation in structure and operation. Progress is variable, with a number of factors affecting this. Good managerial support was helpful for PCN development. The requirement to work together to meet the specific threat of the global pandemic did, in many cases, generate a virtuous cycle by which the experience of working together built trust and legitimacy. The internal dynamics of networks require attention. Pre-existing strong relationships provided a significant advantage. While policy cannot legislate to create such relationships, awareness of their presence/absence is important. Conclusions Networked approaches to service delivery are popular in many health systems. Our use of an explicit evaluation framework supports the extrapolation of our findings to networks elsewhere. We found the framework to be useful in structuring our study but suggest some modifications for future use.

Background: Despite longstanding problems of access to general practice, attempts to understand and address the issues do not adequately include perspectives of the people providing or using care, nor do they use established theories of access to understand complexity.Aim: To understand problems of access to general practice from the multiple perspectives of service users and staff using an applied theory of access.Design and setting: A qualitative participatory case study in an area of northwest England.Method: A community-based participatory approach was used with qualitative interviews, focus groups, and observation to understand perspectives about accessing general practice. Data were collected between October 2015 and October 2016. Inductive and abductive analysis, informed by Levesqueet al’s theory of access, allowed the team to identify complexities and relationships between interrelated problems.Results: This study presents a paradox of problems in accessing general practice, in which the demand on general practice both creates and hides unmet need in the population. Data show how reactive rules to control demand have undermined important aspects of care, such as continuity. The layers of rules and decreased continuity create extra work for practice staff, clinicians, and patients. Complicated rules, combined with a lack of capacity to reach out or be flexible, leave many patients, including those with complex and/or unrecognised health needs, unable to navigate the system to access care. This relationship between demand and unmet need exacerbates existing health inequities.Conclusion: Understanding the paradox of access problems allows for different targets for change and different solutions to free up capacity in general practice to address the unmet need in the population.