INTRODUCTION
The postmillennial family practice has moved far beyond its cottage industry origins. The broader range of services and treatments on offer in modern primary care are maintained by sophisticated medical technologies and an equally diverse and specialised set of care providers. In addition, the service is relied on to promote health and deal with a wider scope of social and psychological issues in the face of disappearing social care and increasing fragmentation of families.1 The growing complexity of the primary care environment and the increasing expectations of patients and policymakers are placing huge demands on the primary care workforce. Recent reports on the challenges and opportunities facing primary care in the UK acknowledge that, to meet these demands, we must realise the potential of all members of the primary care team, including both clinical and non-clinical staff.2,3
Arguably the most visible among the primary care workforce are receptionists, required to work under unprecedented levels of pressure and scrutiny, yet without any concurrent change in their training or support. Their position at the point of entry to the healthcare system means they are the most accessible member of the care team4 and have a significant influence on patients’ perception of their care. They frequently embody the frustrations of patients: a recent survey of complaints in primary care found those concerning receptionists were responsible for nearly half of upheld complaints, the largest figure of any staff group.5 This dissatisfaction with reception staff can have serious implications for non-attendance, increased A&E visits, and health outcomes.6
CLINICAL ROLE OF RECEPTIONISTS
Apparently overlooked by policymakers and undervalued by GPs and patients, receptionists are viewed chiefly as either administrators, undertaking clerical duties to ensure the various office systems continue to support the delivery of care, or ‘gatekeepers’, helping to preserve the boundary of the organisation and controlling access to primary care services.7
The receptionist’s physical isolation at the front desk means that many of their colleagues remain unaware of the complex reality of the various roles they fulfil,5 and it can convincingly be argued that receptionists in the UK also fulfil at least three critically important clinical roles.
First, and one already alluded to, is their role in facilitating access to primary care and the broader health service. Primary care has professionals at the heart of the organisation supported by the administrative infrastructure responsible for controlling access to their services. Receptionists charged with this responsibility are invested with a degree of power and required to exercise discretion. Although perhaps contentious in concept, this leads them to prioritise the allocation of appointments, effectively making triage decisions that can directly affect patient care and outcome.8 Negotiations for appointments are frequently conducted over the telephone, informed by appointment availability and the receptionist’s perception of clinical need, and influenced by patients’ expectations. The frequent lack of structured guidance means that receptionists rely on personal experience and professional intuition to inform their decision making. This subjectivity can lead to receptionists making a ‘moral’, if subconscious, decision about patients founded on a variety of non-clinical factors including appearance, accent, and ethnicity.9 Considering the unsupported exercise of personal judgement in pressured and uncertain conditions, it is perhaps unsurprising that receptionists fulfilling this obligation continue to be a source of complaint and frustration.
Discretion and experience also inform their role in administering repeat prescriptions, the second of the key clinical tasks receptionists perform without specific training or recourse to any formal support. In the UK, half of all patients receive treatment via repeat prescriptions; that is, those issued without consultation between clinician and patient. The process of acquiring such prescriptions is a complex, technology-supported social practice requiring the input of both clinical and administrative staff.10 Although systems and protocols are in place to govern the process, research has described how the sense of responsibility for their patients felt by many receptionists leads them to make often hidden contributions to ensure its successful completion.10 For example, many repeat requests are not listed as repeats on the patient record or reference drugs listed by a different brand name that receptionists would then identify from the formulary.10 In bridging the gaps between the intended process and the actual routine as it plays out in practice, they make extensive use of tacit knowledge and contextual judgements. Again, placing this level of responsibility on untrained staff is unsafe, inadvisable, and leaves patients vulnerable.
The third task of direct clinical consequence undertaken by receptionists is the relaying of test results to patients. A recent UK survey of result communication in primary care found that in 98% of practices the default method of communicating normal test results was via reception staff.11 Previous research has described how this feedback should contain information on the implications of the result, options for further care, and the offer of emotional support. However, the level of detail receptionists provide is restricted by the script supplied by the GP and receptionists lack the training to understand the context of blood results or the discourse styles most suited to communicating such potentially sensitive information. The ensuing uncertainty in patients about the meaning or accuracy of normal results has implications for both patient and the health service, as it can lead to additional costly and unnecessary medical visits and diagnostic procedures.12
THE FUTURE ROLE OF RECEPTIONISTS
In considering these multiple responsibilities, it is apparent that receptionists have a central influence on patient outcome, safety, and satisfaction, and how potential medicolegal concerns might arise for their employers. The breadth and importance of the role of receptionists is now being recognised in the UK and there is anecdotal evidence of changes being implemented at local level. Some practices are attempting to more overtly embed the role in the primary healthcare service; for example, by renaming them ‘medical receptionists’ and extending responsibilities beyond managing clinical appointment schedules to undertaking clinical tasks such as phlebotomy, which were previously the domain of healthcare assistants or phlebotomists.13 Receptionists frequently live in the locale of their surgery7 and this local knowledge has been harnessed to offer effective reassurance to patients,5 and drawn on by GPs to inform their decision making.7 Guidance for receptionists is also emerging around triage, and, although countries such as Australia have already produced standards that offer direction on negotiations of urgency and managing patient appointments,14 in the UK initiatives have tended to be confined to recognising patients with specific conditions such as stroke.15
If the skills and experience of receptionists in the UK are to be more formally supported then the recent investment in improving their training is to be applauded. Some £45 million has been made available to practices since the beginning of the year as part of the wider General Practice Development Programme. The initiative is intended to release capacity in general practice by training receptionists for two clearly defined roles.16 The first is as ‘care navigators’, actively signposting patients to the appropriate service and correct person the first time. The second is as ‘clinical administrators’, managing paperwork such as referral letters to free up GP time to spend with patients.
The move towards the increased use of administrative staff as part of primary care teams is not confined to the UK; internationally the use of support staff is growing and their activities can now include reviewing test results, prescribing, supporting prevention and population health, and performing basic therapeutic interventions.17 However, if any extended role of receptionists is to be integrated and sustained in primary care we need more than training programmes for one or two discrete tasks. Instead, the exact parameters of the receptionist’s work need to be better understood, as do the processes and systems within which they operate. This includes the content of the tasks they perform, the equipment and technology they use, and their relationship with colleagues and their community. However, after decades of underestimating their contribution, it may be that the single most important step is educating patients, policymakers, and GPs as to the potential of receptionists to become an integral part of the primary care service that for so long they have been employed to defend.
Notes
Funding
This work is supported by the Health Foundation (grant number 7452). The ESRC also supported public engagement with this research via the Festival of Social Science.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2017
