Global Reporting Iniciative (GRI)

Most websites consisted of a homepage and pages relating to information about clinicians, booking appointments and the range of clinics and services available (n=77). Several websites contained information about practice policies, mission statements and further information such as practice history, self-help information and newsletters. A minority (n=14) included a link to the practice’s patient information leaflet.

Most practices did not overtly articulate why the website had been developed or the intended aims. Of those which did, the majority stated the intention was to provide patients with easily accessible information about the practice, the workforce and general health information, as well as delivering a patient-centred approach (n=33, 41.8%). The British Medical Association (BMA, 2011 p3) describe patient-centredness as responding

Practices in study sample

(n=85)

Remaining practices after

merger

(n=84)

Practices merged during

data collection

(n=2)

Practices excluded as no

accessible website

(n=5)

Limited demographic data collected from NHS

Choices website

Practice websites included

in analysis

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to individuals’ preferences and patient engagement and participation in decisions about their care. At the time of data collection, practices were also contractually obliged to promote specific online services such as appointment bookings, repeat prescription ordering and access to summary patient records (BMA, 2015b).

Website authorship was unclear. It was attributed on only one website and in this case the author was a GP [Practice 45]. As data collection progressed it became apparent there were similarities across websites both in relation to language used and the way websites were structured. The majority followed a similar structure and common phrases became recognisable, evidence they were following (albeit modified) versions of standardised pre- set templates available from website development companies.

Despite lack of explicit authorship accreditation, websites were predominantly presented from the viewpoint of GPs. This was exemplified by the use of ‘we’ in positioning GPs as the authors of websites. For example, Practice 73 stated ‘We are a small practice of family doctors’. That authorship was implicitly attributed to GPs was also demonstrated by the use of ‘our’ to describe other members of the workforce. So for Practice 58, ‘With the support of our committed practice healthcare team, we will continue to provide a comprehensive primary care service for our patients’. Consequently, although others may have been responsible for website production, GPs were positioned in this role. It was within the context of the positioning of GPs as website authors that websites were interpreted.

Quality of information was highly variable between and within websites, both in relation to information provided and presentation of that information. This may provide insight into the level of importance practices placed on their websites and the public image of their workforce. There was a general lack of attention to the outward-facing presentation of practices across many websites, with broken links, missing information and numerous spelling and grammatical errors. On two websites, text had not been changed from the original example [dummy] text [Practices 18, 55], while on others information directed towards employees was publicly accessible. For example, appraisal procedures, incremental pay award structures [Practice 45], and information for medical students [Practice 65] were easily accessible. Several websites published out-of-date information

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and made reference to Primary Care Trusts which were obsolete two years before data collection occurred.

5.3.2. Practice and Professional Group Profiles

General practices in the study ranged from single-handed practices to multi-practice partnerships with population sizes ranging from 1,675 to 25,593 patients. Practices were situated in rural, suburban and inner city areas. Population deprivation scores covered the entire range from 1 (most deprived) to 10 (least deprived) on the National General Practice Profile Deprivation Scale (Public Health England, 2014). 42.9% of practices in the study sample were in the most deprived areas and 76.2% of practices fell in the bottom 4 deciles. Professional group profiles are detailed in Table 10.

Table 10: Profile by Professional Group General Practitioners

Advanced Nurse Practitioners

Practice Nurses

Practices with staff group N (%) 79 (100) 34 (40.5) 75 (94.9) Number of clinicians stated across websites 450 52 193 % of total qualified clinician workforce (n=695) * 64.7% 7.5% 27.7% Number of practice partners stated across websites (% of profession) 147 (32.7) 3 (5.8) 1 (0.5)

*1 practice employed 2 physician associates and 1 employed a pharmacist practitioner. These were excluded from analysis as they were not the focus of this study

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ANPs were identified as being employed across 40.5% of general practices. However, they made up only a small proportion (7.5%) of the total qualified clinician workforce of GPs, practice nurses and ANPs. ANPs were mostly women (84%) and were most likely to work as a sole ANP.

The introduction of a new General Medical Services Contract in 2004 (GMS, 2004) permitted the development of non-medical partnerships within general practice. Such partnerships could either be solely owned by non-physicians who employed general medical practitioners to deliver some services, or could include one or more non-physician members within a traditional medical partnership. Other commercial and voluntary providers were also permitted to provide primary care services (APMS, DH, 2004). It was anticipated such initiatives would develop new models of working and advance professional roles (The King’s Fund, 2011). In this study ownership of general practices appeared to be dominated by general medical practitioners within traditional medical partnerships, with only five practices (6.3%) identified on websites as being owned by commercial or voluntary providers. No practices were found to be led or primarily owned by ANPs or practice nurses. Three practices each had one ANP partner [Practices 76, 78, 82], two of which were described as ‘associate’ or ‘clinical’ rather than full partners, while one practice nurse was a partner at a single practice [Practice 30]. Both ANP associate/clinical partners worked at average sized practices and while one practice employed two further ANPs, the other associate partner was a sole ANP. The remaining practice with an ANP partner was the largest practice in the sample and employed a further 7 ANPs and 16 GPs. One of the practices with an ANP partner presented comprehensive information about ANP practice on their website [Practice 78].

5.3.3. Summary

This section provided an overview of the sample of general practice websites, set out practice and professional profiles and discussed website quality. Websites were predominantly presented from the position of GPs. Relatively few ANPs worked in general practice. Both ANPs and practice nurses were unlikely to be partners in general practices. Website quality was found to be variable, potentially reflecting a lack of attention to the outward-facing presentation of practices and the public image of practitioners. While this may be attributable to alternative explanations such as limited information technology or public relations skills, it remains that patients and the public were presented with

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inconsistent, unclear and sometimes inaccurate information across many websites. The following sections present themes identified in the study in order to explore the representation and positioning of ANP practice in detail.