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Background: Access to GP appointments is increasingly challenging in many high-income countries, with an overstretched workforce and rising demand. Various access systems have been developed and evaluated internationally., Aim: To systematically consolidate the current international evidence base related to different types of GP access systems., Design and Setting: Scoping review examining international literature., Method: Literature searches were run across relevant databases in May 2022. Title, abstract, and full-text screenings were carried out. Data from included studies were extracted and mapped to synthesise the components and aims within different GP access systems., Results: In total, 49 studies were included in the review. The majority of these were set in the UK. Some access systems featured heavily in the literature, such as Advanced Access, telephone triage, and online consultations, and others less so. There were two key strategies adopted by systems that related to either changing appointment capacity or modifying patient pathways. Components related to these strategies are summarised and illustrated as a schematic representation. Most rationales behind access systems were practice, rather than patient, focused. 'Add-on' systems and aims for efficiency have become more popular in recent years., Conclusion: This synthesis provides a useful tool in understanding access systems' aims, design, and implementation. With focus on alleviating demand, patient-focused outcomes appear to be underinvestigated and potentially overlooked during design and implementation. More recently, digital services have been promoted as offering patient choice and convenience. But a context where demand outweighs resources challenges the premise that extending choice is possible., (© The Authors.)

Background: Health systems are seeking to harness digital tools to promote patient autonomy and increase the efficiency of care worldwide. The NHS Long Term Plan created the right for patients to access 'digital first' primary care by 2023-2024, including online patient access to full medical records., Aim: To identify and understand the unintended consequences of online patient access to medical records., Design and Setting: Qualitative interview study in 10 general practices in South West and North West England., Method: Semi-structured individual interviews with 13 patients and 16 general practice staff with experience of patient online access to health records., Results: Online access generated unintended consequences that negatively impacted patients' understanding of their health care, with patients finding surprising or difficult to interpret information. Online access impacted GPs' documentation practices, such as when GPs pre-emptively attempted to minimise potential misunderstandings to aid patient understanding of their health care. In other cases, this negatively impacted the quality of the records and patient safety when GPs avoided documenting speculations or concerns. Contrary to assumptions that workload would be reduced, online access introduced extra work, such as managing and monitoring access, and taking measures to prevent possible harm to patients., Conclusion: The unintended consequences described by both staff and patients show that, to achieve the intended consequences set out in NHS policy, additional work is necessary to prepare records for sharing and to prepare patients about what to expect. It is crucial that practices are adequately supported and resourced to manage the unintended consequences of online access, now that it is the default position. A table of potential unintended consequences and mitigation measures is provided to aid practice managers and clinicians implementing online access., (© The Authors.)

Background: The COVID-19 pandemic required general practice to rapidly adapt to remote consultations and assessment of patients, creating new, and exacerbating existing, vulnerabilities for many patients., Aim: To explore GP perspectives and concerns about safeguarding practice during the pandemic, focusing on challenges and opportunities created by remote consultation., Design and Setting: Qualitative interview study., Method: Eighteen GPs from Oxford, London, Southampton, Liverpool, Manchester, and Reading were interviewed between June and November 2020, using a flexible topic guide and fictional vignettes to explore child and adult safeguarding scenarios. Interviews were audio-recorded, thematically coded, and analysed., Results: GPs worried about missing observational information during remote consultations and that conversations might not be private or safe. Loss of continuity and pooled triage lists were seen as further weakening safeguarding opportunities. GPs experienced remote consulting as more 'transactional', with reduced opportunities to explore 'other reasons' including new safeguarding needs. However, they also recognised that remote consulting created opportunities for some vulnerable patients. While supporting known vulnerable patients was difficult, identifying new or unknown vulnerabilities was harder still. Most reported that remote consulting during COVID-19 was harder, riskier, and emotionally draining, contributing to increased GP anxiety and reduced job satisfaction., Conclusion: The GPs interviewed raised important concerns about how to identify and manage safeguarding in the context of remote consultations. Current guidance recommends face-to-face consultation for safeguarding concerns, but pressure to use remote forms of access (within or beyond the pandemic) and the fact that safeguarding needs may be unknown makes this an issue that warrants urgent attention., (© The Authors.)

Background: Health services are increasingly using digital tools to deliver care, and online consultations are being widely adopted in primary care settings. The intended consequences of online consultations are to increase patient access to care and increase the efficiency of care., Aim: To identify and understand the unintended consequences of online consultations in primary care., Design and Setting: Qualitative interview study in eight general practices using online consultation tools in South West and North West England between February 2019 and January 2020., Method: Thematic analysis of semi-structured interviews with 19 patients and 18 general practice staff., Results: Consequences of online consultations were identified that restricted patient access to care by making it difficult for some patients to communicate effectively with a GP and disadvantaging digitally-excluded patients. This stemmed from patient uncertainty about how their queries were dealt with, and whether practices used online consultations as their preferred method for patients to contact the practice. Consequences were identified that limited increases in practice efficiency by creating additional work, isolation, and dissatisfaction for some staff., Conclusion: Unintended consequences often present operational challenges that are foreseeable and partly preventable. However, these challenges must be recognised and solutions resourced sufficiently. Not everyone may benefit and local decisions will need to be made about trade-offs. Process changes tailored to local circumstances are critical to making effective use of online consultation tools. Unintended consequences also present clinical challenges that result from asynchronous communication. Online consultation tools favour simple, well-formulated information exchange that leads to diffuse relationships and a more transactional style of medicine., (© The Authors.)

Background: Gut feelings may be useful when dealing with uncertainty, which is ubiquitous in primary care. Both patients and GPs experience this uncertainty but patients' views on gut feelings in the consultation have not been explored., Aim: To explore patients' perceptions of gut feelings in decision making, and to compare these perceptions with those of GPs., Design and Setting: Qualitative interviews with 21 patients in Oxfordshire, UK., Method: Patients whose referral to a cancer pathway was based on their GP's gut feeling were invited to participate. Semi-structured interviews were conducted from November 2019 to January 2020, face to face or over the telephone. Data were analysed with a thematic analysis and mind-mapping approach., Results: Some patients described experiencing gut feelings about their own health but often their willingness to share this with their GP was dependent on an established doctor-patient relationship. Patients expressed similar perspectives on the use of gut feelings in consultations to those reported by GPs. Patients saw GPs' gut feelings as grounded in their experience and generalist expertise, and part of a process of evidence gathering. Patients suggested that GPs were justified in using gut feelings because of their role in arranging access to investigations, the difficult 'grey area' of presentations, and the time- and resource-limited nature of primary care. When GPs communicated that they had a gut feeling, some saw this as an indication that they were being taken seriously., Conclusion: Patients accepted that GPs use gut feelings to guide decision making. Future research on this topic should include more diverse samples and address the areas of concern shared by patients and GPs., (© The Authors.)

Background: The use of gut feelings to guide clinical decision making in primary care has been frequently described but is not considered a legitimate reason for cancer referral., Aim: To explore the role that gut feeling plays in clinical decision making in primary care., Design and Setting: Qualitative interview study with 19 GPs in Oxfordshire, UK., Method: GPs who had referred patients to a cancer pathway based on a gut feeling as a referral criterion were invited to participate. Interviews were conducted between November 2019 and January 2020, and transcripts were analysed using the one sheet of paper method., Results: Gut feeling was seen as an essential part of decision making that facilitated appropriate and timely care. GPs distanced their gut feelings from descriptions that could be seen as unscientific, describing successful use as reliant on experience and clinical knowledge. This was especially true for patients who fell within a 'grey area' where clinical guidelines did not match the GP's assessment of cancer risk, either because the guidance inadequately represented or did not include the patient's presentation. GPs sought to legitimise their gut feelings by gathering objective clinical evidence, careful examination of referral procedures, and consultation with colleagues., Conclusion: GPs described their gut feelings as important to decision making in primary care and a necessary addition to clinical guidance. The steps taken to legitimise their gut feelings matched that expected in good clinical practice., (© The Authors.)

Background: Female genital mutilation (FGM) includes all procedures that intentionally harm or alter female genitalia for non-medical reasons. In 2015, reporting duties were introduced, applicable to GPs working in England including a mandatory reporting duty and FGM Enhanced Dataset. Our patient and public involvement work identified the exploration of potential impacts of these duties as a research priority., Aim: To explore the perspectives of GPs working in England on potential challenges and resource needs when supporting women and families affected by FGM., Design and Setting: Qualitative study with GPs working in English primary care., Method: Semi-structured interviews focused around a fictional scenario of managing FGM in primary care. The authors spoke to 17 GPs from five English cities, including those who saw women who have experienced FGM often, rarely, or never. Interviews were audio recorded and transcribed verbatim for thematic analysis. Lipsky's theory of street-level bureaucracy was drawn on to support analysis., Results: Managing women with FGM was experienced as complex. Challenges included knowing how and when to speak about FGM, balancing care of women and their family's potential care and safeguarding needs, and managing the mandated reporting and recording requirements. GPs described strategies to manage these tensions that helped them balance maintaining patient-doctor relationships with reporting requirements. This was facilitated by access to FGM holistic services., Conclusion: FGM reporting requirements complicate consultations. The potential consequences on trust between women affected by FGM and their GP are clear. The tensions that GPs experience in supporting women affected by FGM can be understood through the theoretical lens of street-level bureaucracy. This is likely to be relevant to other areas of proposed mandated reporting., (© British Journal of General Practice 2020.)

Background: Growing evidence for the role of GPs' gut feelings in cancer diagnosis raises questions about their origin and role in clinical practice., Aim: To explore the origins of GPs' gut feelings for cancer, their use, and their diagnostic utility., Design and Setting: Systematic review and meta-analysis of international research on GPs' gut feelings in primary care., Method: Six databases were searched from inception to July 2019, and internet searches were conducted. A segregated method was used to analyse, then combine, quantitative and qualitative findings., Results: Twelve articles and four online resources were included that described varied conceptualisations of gut feelings. Gut feelings were often initially associated with patients being unwell, rather than with a suspicion of cancer, and were commonly experienced in response to symptoms and non-verbal cues. The pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded (OR 4.24, 95% confidence interval = 2.26 to 7.94); they became more predictive of cancer as clinical experience and familiarity with the patient increased. Despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings as some specialists questioned their diagnostic value. Consequently, some GPs ignored or omitted gut feelings from referral letters, or chose investigations that did not require specialist approval., Conclusion: GPs' gut feelings for cancer were conceptualised as a rapid summing up of multiple verbal and non-verbal patient cues in the context of the GPs' clinical knowledge and experience. Triggers of gut feelings not included in referral guidance deserve further investigation as predictors of cancer. Non-verbal cues that trigger gut feelings appear to be reliant on continuity of care and clinical experience; they tend to remain poorly recorded and are, therefore, inaccessible to researchers., (©The Authors.)

Background: Safety netting is a diagnostic strategy that involves monitoring patients with symptoms possibly indicative of serious illness, such as cancer, until they are resolved. Optimising safety-netting practice in primary care has been proposed to improve quality of care and clinical outcomes. Introducing guidelines is a potential means to achieve this., Aim: To seek the insight of frontline GPs regarding proposed safety-netting guidelines for suspected cancer in UK primary care., Design and Setting: A qualitative interview study with 25 GPs practising in Oxfordshire, UK., Method: Transcripts from semi-structured interviews were analysed thematically by a multidisciplinary research team using a mind-mapping approach., Results: GPs were supportive of initiatives to optimise safety netting. Guidelines on establishing who has responsibility for follow-up, keeping patient details up to date, and ensuring test result review is conducted by someone with knowledge of cancer guidelines were already being followed. Sharing diagnostic uncertainty and ensuring an up-to-date understanding of guidelines were only partially implemented. Neither informing patients of all (including negative) test results nor ensuring recurrent unexplained symptoms are always flagged and referred were considered feasible. The lack of detail, for example, the expected duration of symptoms, caused some concern. Overall, doubts were expressed about the feasibility of the guidelines given the time, recruitment, and resource challenges faced in UK primary care., Conclusion: GPs expressed general support for safety netting, yet were unconvinced that key elements of the guidelines were feasible, especially in the context of pressures on general practice staffing and time., (© British Journal of General Practice 2019.)

Background: Guidelines encourage GPs to make brief opportunistic interventions to support weight loss. However, GPs fear that starting these discussions will lead to lengthy consultations. Recognising that patients are committed to take action could allow GPs to shorten brief interventions., Aim: To examine which patient responses indicated commitment to action, and the time saved if these had been recognised and the consultation closed sooner., Design and Setting: A mixed-method cohort study of UK primary care patients participating in a trial of opportunistic weight management interventions., Method: Conversation analysis was applied to 226 consultation audiorecordings to identify types of responses from patients that indicated that an offer of referral to weight management was well received. Odds ratios (OR) were calculated to examine associations between response types and likelihood of weight management programme attendance., Results: Affirmative responses, for example 'yes', displayed no conversational evidence that the referral was well received and showed no association with attendance: 'yes' (OR 1.2, 95% confidence interval [CI] = 0.37 to 3.95, P = 0.97). However, 'oh'-prefaced responses and marked positive responses, for example 'lovely', showed conversational evidence of enthusiasm and were associated with higher odds of commercial weight management service attendance. Recognising these could have saved doctors a mean of 31 seconds per consultation., Conclusion: When doctors make brief opportunistic interventions that incorporate the offer of help, 'oh'-prefaced or marked positive responses indicate enthusiastic acceptance of the offer and a higher likelihood of take-up. Recognising these responses and moving swiftly to facilitate patient action would shorten the brief intervention in many cases., (© British Journal of General Practice 2018.)

Background: The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments., Aim: The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care., Design and Setting: The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016., Method: Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation., Results: Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists' involvement in implementation and planning for the introduction of alternative approaches to face-to-face consultations was minimal, despite the expectation that they would be involved in delivery., Conclusion: A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations., (© British Journal of General Practice 2018.)

Background: Safety netting is a diagnostic strategy used in UK primary care to ensure patients are monitored until their symptoms or signs are explained. Despite being recommended in cancer diagnosis guidelines, little evidence exists about which components are effective and feasible in modern-day primary care., Aim: To understand the reality of safety netting for cancer in contemporary primary care., Design and Setting: A qualitative study of GPs in Oxfordshire primary care., Method: In-depth interviews with a purposive sample of 25 qualified GPs were undertaken. Interviews were recorded and transcribed verbatim, and analysed thematically using constant comparison., Results: GPs revealed uncertainty about which aspects of clinical practice are considered safety netting. They use bespoke personal strategies, often developed from past mistakes, without knowledge of their colleagues' practice. Safety netting varied according to the perceived risk of cancer, the perceived reliability of each patient to follow advice, GP working patterns, and time pressures. Increasing workload, short appointments, and a reluctance to overburden hospital systems or create unnecessary patient anxiety have together led to a strategy of selective active follow-up of patients perceived to be at higher risk of cancer or less able to act autonomously. This left patients with low-risk-but-not-no-risk symptoms of cancer with less robust or absent safety netting., Conclusion: GPs would benefit from clearer guidance on which aspects of clinical practice contribute to effective safety netting for cancer. Practice systems that enable active follow-up of patients with low-risk-but-not-no-risk symptoms, which could represent malignancy, could reduce delays in cancer diagnosis without increasing GP workload., (© British Journal of General Practice 2018.)

Background: NHS policy encourages general practices to introduce alternatives to the face-to-face consultation, such as telephone, email, e-consultation systems, or internet video. Most have been slow to adopt these, citing concerns about workload. This project builds on previous research by focusing on the experiences of patients and practitioners who have used one or more of these alternatives., Aim: To understand how, under what conditions, for which patients, and in what ways, alternatives to face-to-face consultations present benefits and challenges to patients and practitioners in general practice., Design and Setting: Focused ethnographic case studies took place in eight UK general practices between June 2015 and March 2016., Method: Non-participant observation, informal conversations with staff, and semi-structured interviews with staff and patients were conducted. Practice documents and protocols were reviewed. Data were analysed through charting and the 'one sheet of paper' mind-map method to identify the line of argument in each thematic report., Results: Case study practices had different rationales for offering alternatives to the face-to-face consultation. Beliefs varied about which patients and health issues were suitable. Co-workers were often unaware of each other's practice; for example, practice policies for use of e-consultations systems with patients were not known about or followed. Patients reported benefits including convenience and access. Staff and some patients regarded the face-to-face consultation as the ideal., Conclusion: Experience of implementing alternatives to the face-to-face consultation suggests that changes in patient access and staff workload may be both modest and gradual. Practices planning to implement them should consider carefully their reasons for doing so and involve the whole practice team., (© British Journal of General Practice 2018.)

Background: The ubiquitous use of communication technologies has led to an expectation that a similar approach should extend to health care. Despite considerable rhetoric about the need for general practices to offer alternatives to face-to-face consultations, such as telephone, email, and internet video consultations, the extent to which such technologies are actually used at present is unclear., Aim: The aim of the survey was to identify the frequency and range of ways in which general practices are providing (or planning) alternatives to face-to-face consultations., Design and Setting: A postal survey of practices around Bristol, Oxford, Lothian, the Highlands, and the Western Isles of Scotland., Method: A postal questionnaire survey was sent to each of the GPs and practice managers of 421 practices between January and May 2015., Results: A response was received from 319/421 practices (76%). Although the majority of the practices reported that they were conducting telephone consultations frequently (n = 211/318, 66%), fewer were implementing email consultations (n = 18/318, 6%), and most (n = 169/318, 53%) had no plans to introduce this. None were currently using internet video, and 86% (n = 273/318) had no plans to introduce internet video consultations. These findings were repeated in the reported use of alternatives to face-to-face consultations at an individual GP level. Optional free text responses were completed by 28% of responders, and offered an explanation for the (often perceived) barriers and incentives for implementation., Conclusion: Despite policy pressure to introduce consultations by email and internet video, there is a general reluctance among GPs to implement alternatives to face-to-face consultations. This identifies a substantial gap between rhetoric and reality in terms of the likelihood of certain alternatives (email, video) changing practice in the near future., (© British Journal of General Practice 2016.)

Background: Infertility affects 9% of couples in the UK. Most couples who visit their GP because they are worried about their fertility will ultimately conceive, but a few will not. Treatment usually happens in secondary care, but GPs can have an invaluable role in starting investigations, referring, and giving support throughout treatment and beyond., Aim: To inform clinical practice by exploring primary care experiences of infertility treatment among females and males, and discussing findings with a reference group of GPs to explore practice experience., Design and Setting: A qualitative patient interview and GP focus group study. Interviews were conducted in patients homes in England and Scotland; the focus group was held at a national conference., Method: An in-depth interview study was conducted with 27 females and 11 males. A maximum variation sample was sought and interviews were transcribed for thematic analysis. Results were discussed with a focus group of GPs to elicit their views., Results: Feeling that they were being taken seriously was very important to patients. Some felt that their concerns were not taken seriously, or that their GP did not appear to be well informed about infertility. The focus group of GPs highlighted the role of protocols in their management of patients who are infertile, as well as the difficulty GPs faced in communicating both reassurance and engagement., Conclusion: Simple things that GPs say and do, such as describing the 'action plan' at the first consultation, could make a real difference to demonstrating that they are taking the fertility problem seriously.

Background: Colorectal cancer is the third most common cancer in the UK. Patients with colorectal cancer spend most of their time in the community, but the role of primary care in their management and follow-up is unclear., Aim: To explore colorectal cancer patients' experiences of psychosocial problems and their management in primary and specialist care., Design and Setting: Longitudinal qualitative study of participants recruited from three hospitals in the west of Scotland and interviewed in their own homes., Method: In-depth interviews with 24 participants with a new diagnosis of colorectal cancer, and then follow-up interviews 12 months later., Results: Participants' needs following a diagnosis for colorectal cancer included physical, psychological, and social issues. GPs played a key role in diagnosis, after which they were less involved. Participants valued GPs making unsolicited contact and offering support. Participants described being well supported by clinical nurse specialists who are expert in the illness, and who provide continuity of care and psychological support. A year after diagnosis, when there was less contact with GPs and clinical nurse specialists, participants still faced challenges associated with the ongoing impact of colorectal cancer., Conclusion: While some patients enjoyed straightforward recoveries from surgery, others experienced longer-term implications from their disease and treatment, particularly bowel-function issues, fatigue, anxiety, and sexual problems. The potential for primary care to contribute more to the ongoing care of colorectal cancer patients was identified.

Background: Financial worries may add to the stress experienced by patients and their families, but they are often not discussed with health professionals. People with lung cancer usually have to give up work, and many are terminally ill., Aim: To explore the financial concerns, perceptions and experiences of claiming benefits of people with lung cancer., Design of Study: Qualitative study using narrative interviews., Setting: United Kingdom., Method: Interviews with a maximum variation sample of 45 people with lung cancer, recruited through general practitioners, consultants, nurses and support groups., Results: Some people did not know that they could claim financial benefits, others found claim forms complicated, or were unaware that they had no legal right for important allowances to be backdated. Some people had to 'struggle' to obtain much needed benefits to which they were entitled. Patients below retirement age said that they would prefer to be working, and many were shocked by how hard it was to obtain the information needed to make claims. There was some evidence that even those who are seriously ill, and life-time tax payers, feel stigma in claiming financial help. Nurses, doctors and other patients sometimes offered valuable guidance, but many patients did not receive timely advice. The special social security rules (and DS1500 report form), which might have allowed them to claim benefits more rapidly than usual and at a higher rate, were not always understood., Conclusion: Many reasons were found as to why people with lung cancer have difficulty getting the benefits that they are entitled to. Hospital and primary care staff who handle the issue sensitively and help set claims in motion provide a valuable service that should be replicated throughout the National Health Service.

Background: Many studies (but not all) have shown that for men with testicular cancer a longer treatment delay is associated with additional treatments, greater morbidity, and shorter survival., Aim: This paper explores patients' perspectives on why treatment delays occur., Design: Qualitative study using narrative interviews, Setting: Interviews in patient's homes throughout the United Kingdom (UK)., Method: Interviews with a maximum variation sample of 45 men with testicular cancer, recruited through general practitioners (GPs), urologists, support groups, and charities., Results: Those who sought help relatively quickly responded to symptoms, had heard about testicular cancer in the media, had seen leaflets in GPs' surgeries, or knew others with this disease. Men delayed because they did not recognise signs and symptoms; feared appearing weak, a hypochondriac, or lacking in masculinity; recalled past illness or painful examinations; were embarrassed; feared the consequences of treatment; or lacked time to consult their doctors. Beliefs about symptoms and pessimistic associations with cancer also led to delay. Treatment delays also resulted from misdiagnosis or waiting lists., Conclusion: Whether or not men should be taught to examine themselves routinely to check for testicular cancer is much debated. This study suggests that it is important that men are aware of the normal shape and feel of their testicles, and may benefit from information about signs and symptoms of testicular cancer and the excellent cure rate. Information, provided in surgeries where men feel welcome, might encourage men to seek help promptly when a problem arises. Our study also suggests that GPs may need to accept a low threshold for ultrasound investigation of testicular symptoms and that the ultrasound service needs to be improved. These measures may further reduce mortality and morbidity.