Hello and welcome to BJGP Interviews.

I'm Nada Khan and I'm one of the Associate editors of the Journal.

Thanks for taking the time today to listen to this podcast.

In today's episode, we're speaking to Dr. Charlotte Patterson, who is currently non Executive Director at Royal Papworth Hospital and formerly a Senior fellow and co lead for Primary Care at the Nuffield Trust.

We're here to discuss the paper she's recently published here in the BJGP titled Implications of Skill Mix Change in General Practice Secondary Analysis of Data from the GP Patient Survey.

So, hi, Charlotte, it's really lovely to meet you and to talk about your work and I just really wanted to start by exploring how we know that the composition of the general practice team is evolving with the increasing scope of multidisciplinary work.

Really?

And I wondered if you could just give us some of the context for this work and what you wanted to do here.

Absolutely.

Nada.

So what we really wanted to understand was how two big shifts in policy are shaping the experience of patients care when they come to the GP practice.

Why do we think that was interesting or potentially important?

Basically, we've seen two big changes happening at the same time in the last five years.

So.

So we've seen the shift to multi professional team working with many more different types of health professionals working in general practice and at the same time, separately, we've seen a massive increase in the number of appointments delivered remotely.

So what we wanted to know is what those changes really mean for patients.

We also know that some patients feel confused about who they're seeing and when they turn up to a GP appointment at the surgery, whether that's an appointment with a GP or a physician's associate or a social prescriber.

And this led on to another really important question for us in this study, which is what happens when patients are confused or uncertain about who they've seen and what does that mean for patient trust?

Those are the kinds of questions we wanted to answer.

So this was an analysis of the 2023 GP Patient Survey, which is sent to patients registered in English general practices.

And I think the key thing for this work and what you've outlined just in terms of what you're saying right here, was that the survey asks people who their last general practice appointment was with and whether they had confidence and trust in that person and if their needs were met.

And just given what you were describing, I wanted to move straight on to what you found.

What did the patient say about trust and how did it Vary by different patient characteristics.

Sure.

So what we found in relation to trust.

Nada.

Is that while every 2, 2 in every 3 patients reported they definitely had trust and confidence in the health professional they saw at their GP practice.

And that's very positive.

We also found at the same time, there's a minority of patients, around 7%, who reported they did not at all have confidence and trust in their last GP practice appointment.

And we found that trust is lower among patients who are younger, from minoritised ethnic backgrounds and living in more deprived areas.

So that's what we found in relation to trust.

We also found that patients are confused about different roles of health professionals working in general practice.

And we've found this is likely to affect around one in every 20 patients.

That seems quite a lot, actually, doesn't it?

Yes.

And it's also we found, looking at the GP general practice patient survey, we found that the proportion of patients who feel confused about who they're seeing has gone up over time.

What I can tell you is that if we look backwards over time, the national survey data shows the percentage of patients who are unsure who their last appointment was with has more than doubled in six years.

In 2018, it was around 1.9% of patients.

In the 2024 survey, this had gone up to 5% of patients.

And at the same time, we've also seen a decline in confidence and trust.

So what we can say there is that confidence has declined by around 5% over that same time period.

So 5 percentage points from 69% of patients saying, yes, definitely they had confidence and trust in the health professional they saw in 2018.

But by 2025 that's dropped to 64%.

And I think that almost reflects what's happening in practice with the increasing number of other roles working in general practice as well.

And I think one of the really striking findings here is that patients reported much lower trust when they weren't sure which professional they saw.

Do you want to talk us through that and why you think that is?

Absolutely.

So what we've seen in terms of context here is that a lot of change happening in general practice, much of it taking place at the same time.

So we've seen in terms of multi professional team working, there are 40,000 additional non GP non nurse staff working in general practice, which is a whopping 387% per patient increase over a nine year period.

At the same time, we've also seen this huge policy focus on rapid access, delivering more remote appointments, working at scale and a shift to digital and online as well.

So there's a lot going on in general practice all at the same time.

And we can also see alongside this changes in patients confidence and satisfaction with how general practice is working.

So that's sort of a zoomed out, bigger picture lens.

We can see that in terms of the British Social attitude survey in 2024, almost half of all people said they were quite dissatisfied with how general practice was working.

But looking back in time, if we look back to 1983, we see that only 13% of people were dissatisfied with how general practice was running.

And even looking back just 10 years ago, in 2016, that figure is 16% of the of people in the British Social Attitude Survey who were dissatisfied with general practice.

So we're seeing massive shifts across multiple aspects of general practice.

At the same time, we're seeing a significant shift in the proportion of people who feel that they are satisfied with what's happening in terms of the care they're receiving from general practices.

And I guess that relates to some of the issues with trust and potentially not knowing who people are seeing in practice as well.

Absolutely.

So in our findings, what we found was that the combination of not knowing who you saw and a remote appointment is really problematic for patients in terms of trust and confidence.

So to give a flavour of this, when patients were not sure what health professional, what type of health professional they saw or spoke to, and this was a remote appointment, so an appointment by phone or video or message, the likelihood of reporting confidence and trust decreased by up to 80% when compared to patients who saw a GP in person at their practice.

And we did a podcast with Richard Baker talking about trust in healthcare professionals as well.

And one of the things he highlighted was that actually trust is really important in that patient clinician interaction, because, you know, that trust actually builds some foundation towards whether people might want to come back to the practice, they might want to take up that advice or management that's been suggested by the clinician they see.

So I think not only are you seeing these associations, but it's actually really drilling down to why trust is so important as well in these interactions.

Absolutely, you're 100% right.

And I think we can see.

And Richard Baker spoke to this.

So high trust means that people are less likely to overuse services, so they're less likely to repeatedly seek appointments from different health professionals for the same problem.

But importantly, they're also less likely to underuse services, because high trust means people are more likely to feel confident in presenting themselves as good candidates for care.

For example, trust is Also important for other reasons in general practice.

So about a quarter of all appointments at GP practices are for medically unexplained symptoms.

And that work of managing undifferentiated symptoms is hugely important.

And much of that rests on trust, the trust between a patient and health professional, when actually it's not the right thing to refer for further investigations or treatment.

A lot of that rests on trusting relationships.

And we know that relationship based care, where the patient's more likely to see the same doctor over time, somebody they know, is hugely important.

But at the same time, we've seen a massive drop off and continuity of care.

So if I can speak to the general practice patient survey, what we know is that in the last eight years, continuity of care as reported by patients in England has gone down by around 10 percentage points over the past seven years.

So it was 50% of patients in 2018 who said they were able to see or speak to a preferred doctor.

They had a preferred doctor and they were able to see or speak to them either almost or all of the time.

By 2055, that had reduced and dropped to just 39%.

That's a really meaningful change for patients.

And I think if we look at our study and the results of our study, and we sit that alongside the work of a paper published by Carol Sinot and colleagues recently, we can see that there's real questions about whether the kind of model of care we have is delivering the types of appointments many patients want and need.

And I think Richard Baker talked about this in terms of two kind of different models of care almost.

So this sort of access, dependent, transactional kind of care model on one side, where there are lots of different people working in practice and access, quick access is prioritized, and then the more traditional sort of relationship based care that you're describing as well, that appears to be in decline.

Sadly, the evidence does show that we've seen a significant decline in continuity of care in general practice in the last five, six, seven years.

And that is really challenging for patients as well as for health professionals, because there's good evidence that relationship based care adds to meaning and work.

Joy at work, satisfaction in your job.

It also makes it time efficient to be able to speak and meet with patients whom you already know, particularly if those patients with complex care.

Were there any results from your work here that surprised you when you looked at the data?

That's a really good question.

Nada.

And I think while we understood that there had been so much change in general practice in recent years, trying to map out what that means for patients using evidence.

If I'm honest, I don't think we expected to see the magnitude of the effects.

We saw the likelihood of reporting trust and confidence decreasing by 80%.

When you have an appointment where the patient's not sure who they've seen, they're confused about that and it's a remote appointment, that's a big effect size.

And if I'm honest, that did surprise me.

I think there's things from here that I possibly worried were real and the results confirmed that, so they weren't so much surprising.

But that doesn't take away at all from the level of concern about those.

So one of the things that has concerned me from here, from the results of our study, is that we know that almost 1 in 10 patients said their needs were not at all met in their last general practice appointment.

That's really worrying.

And it's worrying mostly because, well, even more worrying because those living in deprived areas and those with a chronic illness were more likely to report that their needs weren't met.

So that suggests that some of the shifts we've seen in the way that care is organised and delivered may be contributing to the inverse care law.

And that raises some really deep questions about what is the purpose of general practice and how do we ensure that we orientate service delivery models to provide care for patients not only who might prefer or need rapid access for a more transactional type of problem, at the same time as ensuring there's continuity of care and relationship based care for patients who need and will benefit from that model of care.

So these are difficult but important questions for general practice.

And I wonder what your thoughts are about how much of this issue is about communication and expectations rather than the roles themselves.

I think there's a very important element that you're picking up on there.

Nada.

And I do think that communication is a hugely important part of embedding skill mix change successfully into general practice.

So I think it's a complex picture here.

What we can see is that it's really important that GP practices have good systems in place so that when a health professional introduces himself to a new patient, it's expected that they can say, you know, my name is X and I'm a physiotherapist working in this practice, or I'm a physician's associate working in this practice so patients can be clear.

We need clarity on that at both local practice level and also support for that at a national level in terms of successfully implementing some of these changes.

I also think that it's not just about communicating roles.

Well, although that's a very important part of what needs to happen here, we also need to recognise that it's more difficult to establish trust and build rapport in situations where care is delivered remotely.

So thinking about practical strategies to support that sort of building of trust and confidence and knowing who it is that you're seeing when the appointment might be remote.

I think we also need to recognise that the public really worry about not knowing who they're seeing.

And there's a element of social media in contributing to this.

We've seen some high profile cases leading up to a patient's death where the family and the patient have been confused about who it was the patient saw.

And that's hugely upsetting.

It's a significant issue of real public concern.

And I think we need to address those worries and communicate and provide assurance and reassurance for patients, both when they come into practice, but also thinking through how changes are implemented at a national level and whether there's things to learn from some of those experiences.

Yeah, and I just wanted to pick up on that, especially going back to your role and experiences working at the Nuffield Trust.

And we know that national policy is strongly encouraging multi professional teams in general practice.

And do you have any thoughts about what your findings suggest policymakers should think about as these teams expand?

That's a great question, Nana.

I think what we can see is that multidisciplinary team working in primary care is not new, and we do know that it can offer a mix of potential benefits for staff and patients.

But we also know that desired outcomes are not always delivered and we can see that implementation has been really challenging.

So I think there's important reflections there and lessons to be learned about, for example, the importance of building trust and clearly communicating new roles to patients, but also supporting staff and embedding new roles into practice and thinking about the cost of supervisory time to support new roles, to coordinate care, to ensure and avoid fragmenting care.

When you have different members of a team working together to support an individual patient.

So thinking about what's needed to embed those roles successfully and sustain working in general practice, I think what we have to be cautious about is that while there are benefits to patients in terms of increasing access to services and a wider range of services potentially, such as physiotherapy at GP practices or mental health support, that doesn't solve a key fundamental problem for patients who are wanting an appointment with a gp, and in particularly, patients who would prefer to see A GP that they know well and trust.

So, yes, there are more appointments being provided in GP practices, we're seeing more activity, but the question then becomes, are these appointments providing the care that patients want and need?

And if we look at Carol Sinott's paper in the bmj, this suggests that patients may be seeking care, social connection and a sense of being valued, so that both patients and clinicians value personal, longitudinal relationships with a known GP and skill mix.

Change doesn't necessarily easily address that issue and, in fact, it might make the problem more challenging if it fragments care.

And I think we also have to be thoughtful of that in implementation of the new neighbourhood model.

Again, thinking about how do we hardwire continuity of care into new models of service delivery and how do we avoid further fragmenting the care that patients receive at general practice, general practices in England?

Great.

Thank you, Charlotte.

That was so clear.

And I think it's really bringing in a lot of different ideas about how general practice is shifting and being restructured, and crucially, what the patient experience is of all these different changes as well.

So I think this paper has done a really good job of highlighting that from the patient perspective, but I think that's a really great place to wrap things up.

But I just really wanted to say thank you so much for your time here and for talking to us today about this work.

Thank you for having me.

Nada.

It's been a pleasure.

And thank you all very much for your time here and for listening to this BJGP podcast.

Charlotte's original research article can be found on bjgp.org and the show notes and podcast audio can be found@bjgplife.com Charlotte's paper goes into a lot more detail about some of the implications for policy and some of the practical steps that practices can take in terms of introducing new roles and increasing trust in terms of how these roles are introduced to patients.

But thanks again today for listening and bye.