Jennifer Voorhees

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.

The physical spaces in which primary healthcare is delivered matter and have the potential to profoundly affect both patients and staff. This potential is illustrated by academics, who describe the connection between the spaces in which care is delivered and how cared for, and well, patients feel.^1,2,3 Considering healthcare space as a ‘passive background’¹ underestimates its impact.¹ Instead, conceptualising space as ‘active’ better describes its role as ‘participative in the very making of care and health’.¹ While many existing studies focus on hospital settings, there is evidence to suggest that the same is true for primary care.

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.

Background: Good access to primary care is an important determinant of population health. While the academic literature on access to care emphasises its complexity, policies aimed at improving access to general practice in the UK have tended to focus on measurable aspects, such as timeliness or number of appointments.Aim: To fill the gap between the complex understanding of primary care access in the literature and the narrow definition of access assumed in UK policies.Design and setting: Qualitative, community-based participatory case study within the geographic footprint of a clinical commissioning group in the north west of England. Data collection took place from October 2015 to October 2016. Purposive sampling and snowball approaches were used to achieve maximum variation among service users and providers across general practice settings.Method: Levesque et al’s conceptual framework of patient-centred access was applied and the study used multiple qualitative methods (interviews, focus groups, and observation). Analysis was ongoing, iterative, inductive, and abductive with the theory.Results: The comprehensiveness of Levesque et al’s access theory resonated with diverse participant experiences. However, while its strength was to highlight the importance of people’s abilities to access care, this study’s data suggest equal importance of healthcare workforce abilities to make care accessible. Thus, the authors present a definition of access as the ‘human fit’ between the needs and abilities of people in the population and the abilities and capacity of people in the healthcare workforce, and provide a modified conceptual framework reflecting these insights.Conclusion: An understanding of access as ‘human fit’ has the potential to address longstanding problems of access within general practice, focusing attention on the need for staff training and support, and emphasising the importance of continuity of care.

Background: Surveillance of clinically treated self-harm episode frequency is an important component of suicide prevention in the dynamic context of COVID-19. Studies published to date have investigated the initial months following the onset of the pandemic, despite national and regional restrictions persisting to Summer 2021. Methods: We conducted a descriptive time series analysis utilising data from the Greater Manchester Care Record, which contains de-identified, primary care health records of 2.8 million patients. Counts of incident and all episodes of self-harm recorded between 1 ^st January 2019 and 31 ^st May 2021 were made for all patients, with stratification by sex, age group, ethnicity, and index of multiple deprivation (IMD) quintile and examination of overall differences by national and regional restriction phases. Findings: Between 1st January 2019 and 31 ^st May 2021, 33,444 episodes of self-harm by 13,148 individuals were recorded. Frequency ratios of incident and all episodes of self-harm were 0.59 (95% CI 0.51 to 0.69) and 0.69 (CI 0.63 to 0.75) respectively in April 2020 compared to February 2020. Between August 2020 and May 2021 frequency ratios were 0.92 (CI 0.88 to 0.96) for incident episodes and 0.86 (CI 0.84 to 0.88) for all episodes compared to the same months in 2019. Reductions were largest among men and people living in the most deprived neighbourhoods. An increase in all-episode self-harm (frequency ratio 1.09, CI 1.03 to 1.16) was observed for adolescents aged 10-17 between August 2020 and May 2021. Interpretation: The COVID-19 pandemic has had a sustained impact on help seeking for self-harm. Reductions in primary care recorded self-harm have implications for clinicians’ ability to assess the needs and risks of individuals. Some patients may be experiencing prolonged untreated deterioration in their mental health while other groups are presenting in higher numbers. Our findings have important implications for primary care and mental health services in manging ongoing demand. Funding: UKRI COVID-19 Rapid Response Initiative (grant reference COV0499), University of Manchester Presidential Fellowship (SS), and NIHR Greater Manchester Patient Safety Translational Research Centre.