Showing papers in "BJGP open in 2022"

Clinical risk in remote consultations in general practice: findings from in-COVID-19 pandemic qualitative research

Abstract: Background The COVID-19 pandemic-related rise in remote consulting raises questions about the nature and type of risks in remote general practice. Aim To develop an empirically based and theory-informed taxonomy of risks associated with remote consultations. Design & setting Qualitative sub-study of data selected from the wider datasets of three large, multi-site, mixed-method studies of remote care in general practice before and during the COVID-19 pandemic in the UK. Method Semi-structured interviews and focus groups, with a total of 176 clinicians and 43 patients. Data were analysed thematically, taking account of an existing framework of domains of clinical risk. Results The COVID-19 pandemic brought changes to estates (for example, how waiting rooms were used), access pathways, technologies, and interpersonal interactions. Six domains of risk were evident in relation to the following: (1) practice set-up and organisation (including digital inequalities of access, technology failure, and reduced service efficiency); (2) communication and the clinical relationship (including a shift to more transactional consultations); (3) quality of clinical care (including missed diagnoses, safeguarding challenges, over-investigation, and over-treatment); (4) increased burden on the patient (for example, to self-examine and navigate between services); (5) reduced opportunities for screening and managing the social determinants of health; and (6) workforce (including increased clinician stress and fewer opportunities for learning). Conclusion Notwithstanding potential benefits, if remote consultations are to work safely, risks must be actively mitigated by measures that include digital inclusion strategies, enhanced safety-netting, and training and support for staff.

Patients’ and physicians’ experiences with remote consultations in primary care during the COVID-19 pandemic: a multi-method rapid review of the literature

Abstract: During the COVID-19 pandemic, many countries implemented remote consultations in primary care to protect patients and staff from infection.The aim of this review was to synthesise the literature exploring patients' and physicians' experiences with remote consultations in primary care during the pandemic, with the further aim of informing their future delivery.Rapid literature review.PubMed and PsychInfo were searched for studies that explored patients' and physicians' experiences with remote consultations in primary care. To determine the eligibility of studies, their titles and abstracts were reviewed, before the full article. Qualitative and quantitative data were then extracted from those that were eligible, and the data synthesised using thematic and descriptive synthesis.A total of 24 studies were eligible for inclusion in the review. Most were performed in the US (n = 6, 25%) or Europe (n = 7, 29%). Patient and physician experiences were categorised into perceived 'advantages' and 'issues'. Key advantages experienced by patients and physicians included 'reduced risk of COVID-19' and 'increased convenience', while key issues included 'a lack of confidence in or access to required technology' and a 'loss of non-verbal communication' which degraded clinical decision-making.This review identified a number of advantages and issues experienced by patients and physicians using remote consultations in primary care. The results suggest that, while remote consultations are more convenient and protect patients and staff against COVID-19, they result in the loss of valuable non-verbal communication, and are not accessible to all.

Patients’ and clinicians’ perspectives on the primary care consultations for acute respiratory infections during the first wave of the COVID-19 pandemic: an eight-country qualitative study in Europe

Abstract: The impact of the COVID-19 pandemic on patients' and clinicians' perceptions of healthcare-seeking behaviour and delivery of care is unclear. The pandemic accelerated the use of remote care, and understanding its benefits and drawbacks may inform its implementation during current and future healthcare emergencies.To explore patients' and primary care professionals' (PCPs) experiences of primary care delivery in the first wave of the pandemic.Qualitative study using semi-structured interviews in primary care in eight European countries (England, Ireland, Belgium, the Netherlands, Greece, Poland, Sweden, and Germany).A total of 146 interviews were conducted with 80 PCPs and 66 patients consulting for respiratory tract infection (RTI) symptoms, in eight European countries. Data were collected between April and July 2020, and analysed using thematic analysis.It was found that patients accepted telemedicine when PCPs spent time to understand and address their concerns, but a minority preferred in-person consultations. PCPs felt that remote consultations created emotional distance between themselves and patients, and they reported having to manage diverse COVID-19-related medical and social concerns.Remote consultations for RTI symptoms may be acceptable long term if both groups are happy to use this format, but it is important that PCPs take time to address patients' concerns and provide safety-netting advice.

Enhancing the management of long COVID in general practice: a scoping review

Abstract: Long COVID is a multifaceted condition, and it has impacted a considerable proportion of those with acute COVID-19. Affected patients often have complex care needs requiring holistic and multidisciplinary care, the kind routinely provided in general practice. However, there is limited evidence regarding GP interventions.This study aimed to identify key concepts and knowledge gaps around long COVID by conducting a scoping review of literature on the condition's management by GPs.Arksey and O'Malley's six-stage scoping review framework, with recommendations by Levac et al, was used.PubMed, Google Scholar, the Cochrane Library, Scopus, and Google searches were conducted to identify relevant peer reviewed and grey literature, and study selection process was conducted according to the PRISMA Extension for Scoping Reviews guidelines. Braun and Clarke's 'Thematic Analysis' approach was used to interpret data.Nineteen of 972 identified articles were selected for review. These included peer reviewed articles and grey literature spanning a wide range of countries. Six themes were identified regarding GP management of long COVID, these being: (1) GP uncertainty, (2) listening and empathy, (3) assessment and monitoring of symptoms, (4) coordinating access to appropriate services, (5) facilitating provision of continual and integrated multidisciplinary care and (6) need to provide or facilitate psychological support.The findings show that GPs can play and have played a key role in the management of long COVID, and that patient care can be improved through better understanding of patient experiences, standardised approaches for symptom identification and treatment, and facilitation of access to multidisciplinary specialist services when needed. Future research evaluating focused GP interventions is needed.

Telehealth use in patients with type 2 diabetes in Australian general practice during the COVID-19 pandemic: a retrospective cohort study

Abstract: The Australian government introduced temporary government-subsidised telehealth service items (phone and video-conference) in mid-March 2020 in response to the COVID-19 pandemic. The uptake of telehealth by patients with type 2 diabetes (T2DM) for consulting with GPs is unknown.To evaluate the uptake of telehealth consultations and associated patient characteristics in Australian general practice, including the frequency of haemoglobin A1c (HbA1c) tests and change in HbA1c levels by telehealth use, compared with guideline recommendations.This exploratory study used electronic patient data from approximately 800 general practices in Victoria and New South Wales (NSW), Australia. A pre-COVID-19 period from March 2019-February 2020 was compared with a pandemic period from March 2020-February 2021. Patients diagnosed with T2DM before March 2018 were included.Telehealth uptake patterns were examined overall and by patient characteristics. Generalised estimating equation models were used to examine patient probability of 6-monthly HbA1c testing and change in HbA1c levels, comparing between patients who did and patients who did not use telehealth.Of 57 916 patients, 80.8% had telehealth consultations during the pandemic period. Telehealth consultations were positively associated with patients with T2DM who were older, female, had chronic kidney disease (CKD), prescribed antidiabetic medications, and living in remote areas. No significant difference was found in 6-monthly HbA1c testing and HbA1c levels between telehealth users and patients who had face-to-face consultations only.Telehealth GP consultations were well utilised by patients with T2DM. Diabetes monitoring care via telehealth is as effective as face-to-face consultations.

Physical activity promotion by GPs: a cross-sectional survey in England

Abstract: Background Physical activity (PA) contributes to the prevention and management of many health conditions. Primary care practitioners have an important role to play in supporting people to be physically active. Aim This study had the following three aims: 1) to explore GPs‘ awareness and knowledge of the PA guidelines; 2) to assess GPs’ confidence in promoting PA; and 3) to explore factors that influence PA promotion among GPs. Design & setting Cross-sectional survey, using secondary analysis. Method UK-based GPs were invited to take part in an online survey in January 2021. Demographic questions were followed by nine multiple choice questions. Categorical data were analysed using descriptive statistics, and open-ended data were analysed using content analysis and inductive coding. Results In total, 839 GPs based in England completed the survey. Most GP responders (98.9%) believed that PA was important, yet only 35.7% reported being at least ‘somewhat familiar’ with current PA guidance. Despite this, 74.1% of GPs reported feeling confident raising the topic of PA with their patients. Barriers included lack of time, perceptions of patient attitude and risk, language issues, and COVID-19. Key facilitators were identified and ‘Couch to 5k’ and the ‘parkrun practice’ initiatives were the most widely used support tools. Conclusion GPs value PA yet well-known barriers exist to embedding promotion into primary care. As primary care reconfigures, there is an opportunity to embed PA into systems, services, and processes.

Virtual care in Ontario community health centres: a cross-sectional study to understand changes in care delivery

Abstract: Background There has been a large-scale adoption of virtual delivery of primary care as a result of the COVID-19 pandemic. Aim In this descriptive study, an equity lens is used to explore the impact of transitioning to greater use of virtual care in community health centres (CHCs) across Ontario, Canada. Design & setting A cross-sectional survey was administered and electronic medical record (EMR) data were extracted from 36 CHCs. Method The survey captured CHCs‘ experiences with the increased adoption of virtual care. A longitudinal analysis of the EMR data was conducted to evaluate changes in health service delivery. EMR data were extracted monthly for a period of time before the pandemic (April 2019–February 2020) and during (April 2020–February 2021). Results In comparison with the pre-pandemic period, CHCs experienced a moderate decline in visits made (11%), patients seen (9%), issues addressed (9%), and services provided (15%). During the pandemic period, an average of 54% of visits were conducted virtually, with telephone as the leading virtual modality (96%). Drops in service types ranged from 28%–82%. The distribution of virtual modalities varied according to the provider type. Access to in-person and virtual care did not vary across patient characteristics. Conclusion The results demonstrate a large shift towards virtual delivery while maintaining in-person care. No meaningful differences were found in virtual versus in-person care related to patient characteristics or rurality of centres. Future studies are needed to explore how to best select the appropriate modality for patients and service types.

Barriers and facilitators to primary care research: views of GP trainees and trainers

Abstract: Background Primary care plays an important role in the conception and delivery of transformational research but GP engagement is lacking, prompting calls for the promotion of academic opportunities in primary care. Aim To identify potential barriers and facilitators among GP trainees and trainers in primary care research to inform support given by Local Clinical Research Networks (LCRNs). Design & setting A cross-sectional online survey was developed and distributed by the CRN to GP trainees and trainers in the North East and North West. Method The survey covered areas including demographics, career intentions, current and potential engagement with research, as well as their general understanding of research in primary care, which included barriers and facilitators to primary care research. Results Trainees had low intentionality to pursue research and half of trainees did not engage with any research activity. Despite one in five trainees reporting intentions to include research in their career, only 1% would undertake a solely academic career. Medical school region was the only strongly associated factor with academic career intention. Just under 30% of trainers reported engagement in research, but far fewer (8.6%) were interested in contributing to research, and only 10% felt prepared to mentor in research. Conclusion Among trainees, there is limited engagement in and intentionality to pursue research, and this was crucially reflected by responses from trainers. This study identified the need for LCRNs to assist with training in research mentoring and skills, funding opportunities, and to develop resources to promote research in primary care.

Understanding social care need through primary care big data: a rapid scoping review

Abstract: A more comprehensive understanding and measurement of adult social care need could contribute to efforts to develop more effective, holistic personalised care, particularly for those with multiple long-term conditions (MLTC). Progress in this area faces the challenge of a lack of clarity in the literature relating to how social care need is assessed and coded within variables included in primary care databases.To explore how social care need is assessed and coded within variables included in primary care databases.An exploratory rapid scoping review of peer-reviewed articles and grey literature.Articles were screened and extracted onto a charting sheet and findings were summarised descriptively. Articles were included if published in English and related to primary and social care using data from national primary care databases.The search yielded 4010 articles. Twenty-seven were included. Six articles used the term 'social care need', although related terminology was identified including 'need factors', 'social support', and 'social care support'. Articles mainly focused on specific components of social care need, including levels of social care usage or service utilisation and costs incurred to social care, primary care, and other providers in addressing needs. A limited range of database variables were found measuring social care need.Further research is needed on how social care need has been defined in a UK context and captured in primary care big databases. There is potential scope to broaden the definition of social care need, which captures social service needs and wider social needs.

Effectiveness of preconception care interventions in primary care: a systematic review protocol

Abstract: Pregnancy outcomes can be adversely affected by a range of modifiable risk factors, including alcohol consumption, smoking, obesity, drug use, and poor nutrition, during the preconception period. Preconception care (PCC) involves interventions that identify and seek to change behavioural, biomedical, and social risks present in reproductive-aged women and men. Primary care is well situated to offer PCC interventions but the effectiveness of these interventions is not clear.To evaluate the effectiveness of primary care-based PCC delivered to reproductive-aged women and/or men to improve health knowledge, reduce preconception risk factors, and improve pregnancy outcomes.A systematic review of primary care-based PCC.Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Scopus, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases will be searched for English language studies published between July 1999 and May 2021. For inclusion, the PCC intervention must be provided in a primary care setting and intervention recipients must be reproductive-aged women and/or men. All stages of screening and data extraction will involve a dual review. The Cochrane Risk of Bias 2 (RoB 2) for randomised controlled trials (RCTs) will be used to assess the methodological quality of studies. This protocol adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) reporting guidelines.Findings will determine the effectiveness of primary care-based preconception interventions delivered to reproductive-aged women and men on improving health knowledge, reducing risk factors, and improving pregnancy outcomes. Findings will be published in a peer-reviewed journal.

The Veteran Friendly Practice accreditation programme: a mixed-methods evaluation

Abstract: Background The Royal College of General Practitioners (RCGP) Veteran Friendly Practice Accreditation Programme launched in 2019, aiming to allow practices to better identify, treat, and refer veterans, where appropriate, to dedicated NHS services. Aim To evaluate the effectiveness of the accreditation programme, focusing on benefits for the veteran, the practice, and the delivery of the programme itself. Design & setting The study evaluated the views of veteran-friendly accredited GP practices across England. Method A mixed-methods study was undertaken, which collected data via an online survey from 232 accredited primary healthcare (PHC) staff and 15 semi-structured interviews with PHC veteran leads. Interviews were analysed using modified grounded theory. Results The study found 99% ( n = 228) of responders would recommend the programme, 78% ( n = 180) reported improved awareness, and 84% ( n = 193) a better understanding of veterans' needs. Seventy-two per cent ( n = 166) identified benefits for veterans who were engaging more with PHC but participants felt more time was needed, largely owing to the COVID-19 pandemic, to fully assess the impact of the programme on help-seeking behaviour. Challenges included identifying veterans already registered, promoting the accreditation process, and ensuring all PHC staff were kept up to date with veteran issues. Conclusion The programme has increased signposting to veteran-specific services and resulted in greater understanding of the NHS priority referral criteria for veterans. Recording of veteran status has improved and there was evidence of a better medical record coding system in PHC practices. These findings add to the limited empirical evidence exploring veteran engagement in PHC, and demonstrate how accreditation results in better treatment and identification of veterans.

How do UK general practice staff understand and manage prediabetes? A focus group study

Abstract: Preventing type 2 diabetes is a national priority; one aspect is the identification and active management of 'prediabetes' through lifestyle change.To explore what primary care clinicians understood by 'prediabetes', how they communicated this diagnosis to people, how they delivered lifestyle advice, and their views on barriers to lifestyle change.Three focus groups were undertaken with 25 individuals from primary care teams (GPs, nurses, and healthcare assistants) in Newham, a deprived and ethnically diverse part of London, UK.Recordings were transcribed verbatim and analysed thematically before integrating social and behavioural science theories.Focus groups participants described four main influences on their management of prediabetes in the consultation: social determinants, clinical aspects of diagnosis and management, patient motivation and behaviour change, and long-term care. Since most felt unable to address social determinants such as poverty, discussions with patients tended to focus on attempts to change individual behaviours and achieve particular numerical targets, with limited attention to the social context in which behaviours would play out.Type two diabetes prevention efforts in general practice may fail to address the upstream causes of this disease. A narrow focus on numerical targets and decontextualised behaviours overlooks the social complexity of human behaviour and lifestyle choices. Within the consultation, the authors recommend that greater attention is paid to discussing the social context and meaning of particular behaviours. Beyond the consultation, collaboration between primary care clinicians, public health bodies, and local governments is required to address community-level constraints to behaviour change.

Clinical prediction rules for childhood urinary tract infections: a cross-sectional study in ambulatory care

Abstract: Diagnosing childhood urinary tract infections (UTIs) is challenging. Clinical prediction rules may help to identify children that require urine sampling. However, there is a lack of research to determine the accuracy of the scores in general practice.To validate clinical prediction rules (UTI Calculator [UTICalc], A Diagnosis of Urinary Tract Infection in Young Children [DUTY], and Gorelick score) for paediatric UTIs in primary care.Post-hoc analysis of a cross-sectional study in 39 general practices and two emergency departments (EDs). The study took place in Belgium from March 2019-March 2020.Physicians recruited acutely ill children aged ≤18 years and sampled urine systematically for culture. Per rule, an apparent validation was performed, and sensitivities and specificities were calculated with 95% confidence intervals (CIs) per threshold in the target group. For the DUTY coefficient-based algorithm, a logistic calibration was performed and the area under the receiver operating characteristic curve (AUC) was calculated with 95% CI.Of 834 children aged ≤18 years recruited, there were 297 children aged <5 years. The UTICalc and Gorelick score had high-to-moderate sensitivity and low specificity: UTICalc (≥2%) 75% and 16%, respectively; Gorelick (≥2 variables) 91% and 8%, respectively. In contrast, the DUTY score ≥5 points had low sensitivity (8%) but high specificity (99%). Urine samples would be obtained in 72% versus 38% (UTICalc), 92% versus 38% (Gorelick) or 1% versus 32% (DUTY) of children, compared with routine care. The number of missed infections per score was 1/4 (UTICalc), 2/23 (Gorelick), and 24/26 (DUTY). The UTICalc + dipstick model had high sensitivity and specificity (100% and 91%), resulting in no missed cases and 59% (95% CI = 49% to 68%) of antibiotics prescribed inappropriately.In this study, the UTICalc and Gorelick score were useful for ruling out UTI, but resulted in high urine sampling rates. The DUTY score had low sensitivity, meaning that 92% of UTIs would be missed.

Diagnostic accuracy of the FRAIL scale plus functional measures for frailty screening: a cross-sectional study

Abstract: There is little knowledge of the diagnostic accuracy of screening programmes for frailty in primary care settings.To assess a two-step strategy consisting of the administration of the FRAIL scale to those who are non-dependent, aged ≥75 years, followed-up by measurement of the Short Physical Performance Battery (SPPB) or gait speed in those who are positive.Cross-sectional and longitudinal cohort study. Analysis of primary care data from the FRAILTOOLS project at five European cities.All patients consecutively attending were enrolled. They received the index tests plus the Fried phenotype and the frailty index to assess their frailty status. Mortality and worsening of dependency in basic (BADL) and instrumental (IADL) activities of daily living over a year were ascertained.Prevalence of frailty based on frailty phenotype was 14.9% in the 362 participants. A FRAIL scale score ≥1 had a sensitivity of 83.3% (95%CI:73.1-93.6) to detect frailty. A positive result and a SPPB score <11 had a sensitivity of 72.2% (95%CI: 59.9-84.6); when combined with a gait speed <1.1 m/s, the sensitivity was 80% (95%CI: 68.5-91.5). Two thirds of those screened as positive were not frail. In the best scenario, sensitivities of this last combination to detect IADL and BADL worsening were 69.4% (95%CI: 59.4-79.4) and 63.6% (95%CI: 53.4-73.9).Combining the FRAIL scale with other functional measures offers an acceptable screening approach for frailty. Accurate prediction of worsening dependency and death need to be confirmed through the piloting of a frailty screening programme.

Patient experiences during the COVID-19 pandemic: a qualitative study in Dutch primary care

Abstract: Changes in primary care provision during the COVID-19 pandemic could have affected patient experience of primary care both positively and negatively.To assess the experiences of patients in primary care during the COVID-19 pandemic.A qualitative study of patients from regions with high and low COVID-19 prevalence in the Netherlands.A qualitative study using a phenomenological framework was performed among purposively sampled patients. Individual semi-structured interviews were performed and transcribed. Data were thematically analysed by means of an inductive approach.Twenty-eight patients were interviewed (13 men and 15 women, aged 27-91 years). After thematic analysis, two main themes emerged: accessibility and continuity of primary care. Changes considered positive during the pandemic regarding accessibility and continuity of primary care included having a quieter practice, having more time for consultations, and the use of remote care for problems with low complexity. However, patients also experienced decreases in both care accessibility and continuity, such as feeling unwelcome, the GP postponing chronic care, seeing unfamiliar doctors, and care being segregated.Despite bringing several benefits, patients indicated that the changes to primary care provision during the COVID-19 pandemic could have threatened care accessibility and continuity, which are core values of primary care. These insights can guide primary care provision not only in this and future pandemics, but also when implementing permanent changes to care provision in primary care.

Augmented video consultations in care homes during the COVID-19 pandemic: a qualitative study

Abstract: The COVID-19 pandemic necessitated an unprecedented implementation of remote consultations in UK primary care services. Specifically, older adults in care homes had a high need for infection prevention owing to their existing health conditions. GP practices in the East Midlands incorporated augmented video consultations (AVC) with the potential to support remote healthcare assessments for older adults at care homes.To explore GPs' and care home staff's experiences of the use of AVC as a mechanism to perform remote examinations of older adults in care homes.Qualitative interviews were conducted with GPs and care home staff in the East Midlands, UK, during May-August 2020.A convenience sample of GPs (n = 5), nurses (n = 12), and senior healthcare assistants (n = 3) were recruited using a purposive approach. Data were collected through semi-structured telephone interviews and analysed using framework analysis.Findings from participants indicated that AVC enabled real-time patient examinations to aid diagnosis and promoted person-centred care in meeting the needs of older adults. The participants also discussed the challenges of video consultations for patients with cognitive impairment and those receiving end-of-life care.AVCs show great potential in terms of GPs providing primary care services for care homes. However, healthcare staff must be involved in the development of the technology, and consideration should be given to the needs of older adults with cognitive impairment and those receiving end-of-life care. It is also vital that training is available to encourage confidence and competency in implementing the technology.

GPs' experiences of a collaborative care model for patients with common mental disorders who need sick leave certification: a qualitative study

Abstract: GPs are an important part of collaboration around patients with common mental disorders (CMD) in primary care. The Co-Work-Care model was implemented to further improve collaboration, and emphasised working more closely with patients through active dialogues among care managers, rehabilitation coordinators, and GPs. This enhanced collaborative model also included a person-centred dialogue meeting with patients' employers.The aim of this study was to explore GPs' experiences of the Co-Work-Care model, an organisation of collaborative care at the primary care centre (PCC) that includes a person-centred dialogue meeting in the care of patients with CMD who need sick leave certification.Qualitative individual and group interviews were conducted with Swedish GPs with experience of the Co-Work-Care trial where the PCC was an intervention PCC with the enhanced collaboration model.GPs were sampled purposefully from different Co-Work-Care intervention PCCs in Sweden. Focus group and individual, in-depth semi-structured interviews were conducted. All interviews were analysed by systematic text condensation (STC), according to Malterud.The following three codes describing the GPs' experiences of working in the Co-Work-Care model were identified: (1) a structured work approach; (2) competency of the care manager and the rehabilitation coordinator; and (3) gaining control through close collaboration.Overall, GPs' experience was that the enhanced collaboration reduced their workload and enabled them to focus on medical care. Patient care was perceived as safer and more effective. These advantages may result in higher quality in medical and rehabilitation decisions, as well as a more sustainable and less stressful work situation for GPs.

Concerns regarding tablet splitting: a systematic review

Abstract: Tablet splitting can provide dose flexibility and cost savings; however, pharmaceutical representatives typically discourage the practice.To identify and summarise all published concerns related to tablet splitting and to present the experimental evidence that investigates those concerns.Systematic review and qualitative synthesis of tablet-splitting concerns and evidence.Medline and EMBASE databases were searched over all years of publication for articles in English discussing the splitting of tablets. Eligible articles included original research, narrative reviews, systematic reviews, and expert opinion.After removing duplicates, 1837 potentially relevant articles underwent dual review, whereupon 1612 articles were excluded based on title and abstract. After examination of 225 full texts, 138 articles were included (one systematic review, four narrative reviews, 101 original research articles, and 32 opinion articles). The described concerns included difficulty breaking tablets, loss of mass, weight variability, chemical instability, overly rapid dosing if sustained-release medications are split, non-compliance, and patient confusion resulting in medication errors. No substantive evidence was found to support concerns regarding loss of mass, weight variability, chemical instability, or non-compliance. Evidence does support some older adults struggling to split tablets without tablet splitters, and the inappropriateness of splitting sustained-release preparations, given the potential for alteration of the rate of drug release for some products.With the exception of sustained-release tablets, which should not be split, and excepting those older people who may struggle to split tablets based on physical limitations, there is little evidence to support tablet-splitting concerns.

Establishing a Deep End GP group: a scoping review

Abstract: Background GPs working in deprived areas, where all-cause mortality rates are higher compared to less deprived areas, face unique challenges. Despite 50 years passing since Tudor Hart’s seminal ‘inverse care law’ paper, the health inequities gap remains wide. Deep End GP groups are frontline GP-led initiatives working to close this gap and improve the health and lives of those most in need. Aim To use scoping methodology to map out the process of creating a Deep End GP group. Design & setting A scoping review using Arksey and O’Malley’s framework. Method MEDLINE, Embase, Web of Science, and CINAHL databases, as well as non-peer reviewed publications, were searched and articles extracted, reviewed, and analysed according to iterative inclusion criteria. Results From an initial search number of 35 articles, 16 articles were included in the final analysis. Key steps in starting a Deep End GP group were: quantifying patients and practices in areas of deprivation; establishing GP-led objectives at an initial meeting; regular steering group meetings with close collaboration between academic and frontline general practice, as well as the wider multidisciplinary team; and adopting a local Deep End logo. Conclusion Deep End GP groups have made advances to reduce health impacts of systemic health inequities. Starting a Deep End GP group involves a multidisciplinary approach, beginning with the identification of patients and practices in areas of highest need. The findings and key themes identified in this scoping review will guide interested parties to start the journey to do the same in their locality and to join the Deep End movement.

Unrecognized depression among the elderly: a cross-sectional study from norwegian general practice.

Abstract: BACKGROUND Depression is common in old age and is associated with both disability, increased mortality and increased impairment from physical diseases. AIM To estimate the prevalence of depression among old patients in Norwegian general practice, to evaluate the extent they talk about it during their consultation, if it was previously known or suspected by their general practitioner (GP), and how frequent the depressed patients visit their GP. DESIGN & SETTING Cross-sectional study among patients and GPs at 18 primary care clinics in the south of Norway. METHOD Patients ≥65 years who visited their GP were asked to complete the Patient Health Questionaire-9 (PHQ9). The GPs reported what kind of issues the patient presented at the consultation, if a current depression were known, and the consultation frequency. RESULTS 44 (11%) of 383 patients reported moderate or severe depressive symptoms (PHQ9 ≥10). Among the cases with data from both patient and GP (369), 38 patients (10%) reported moderately depressive symptoms. Of these only 12 (32%) mentioned psychological problems to their GP during their consultation, 12 (32%) were neither known to the GP with previous depression nor suspected by the GP of having a current one, and 68% of them visit their GP ≥5 times a year. CONCLUSION Elderly patients tend to speak little of their depression to the GP. Almost 1 of 3 elderly patients with moderate depressive symptoms were unrecognised by their GP. GPs should more often suspect potential mental health problems in old patients who come frequently to visits.

The Veteran Friendly Practice accreditation programme: a mixed-methods evaluation.

Abstract: The Royal College of General Practitioners (RCGP) Veteran Friendly Practice Accreditation Programme launched in 2019, aiming to allow practices to better identify, treat, and refer veterans, where appropriate, to dedicated NHS services.To evaluate the effectiveness of the accreditation programme, focusing on benefits for the veteran, the practice, and the delivery of the programme itself.The study evaluated the views of veteran-friendly accredited GP practices across England.A mixed-methods study was undertaken, which collected data via an online survey from 232 accredited primary healthcare (PHC) staff and 15 semi-structured interviews with PHC veteran leads. Interviews were analysed using modified grounded theory.The study found 99% (n = 228) of responders would recommend the programme, 78% (n = 180) reported improved awareness, and 84% (n = 193) a better understanding of veterans' needs. Seventy-two per cent (n = 166) identified benefits for veterans who were engaging more with PHC but participants felt more time was needed, largely owing to the COVID-19 pandemic, to fully assess the impact of the programme on help-seeking behaviour. Challenges included identifying veterans already registered, promoting the accreditation process, and ensuring all PHC staff were kept up to date with veteran issues.The programme has increased signposting to veteran-specific services and resulted in greater understanding of the NHS priority referral criteria for veterans. Recording of veteran status has improved and there was evidence of a better medical record coding system in PHC practices. These findings add to the limited empirical evidence exploring veteran engagement in PHC, and demonstrate how accreditation results in better treatment and identification of veterans.

Retention of medical officers in district health services, South Africa: a descriptive survey

Abstract: The health workforce is critical to strengthening district health services (DHS). In the public sector of South Africa, medical officers (MOs) are essential to delivering services in primary health care (PHC) and district hospitals. Family physicians, responsible for clinical governance, identified their retention as a key issue.To evaluate factors that influence retention of MOs in public sector DHS.A descriptive survey of MOs working in DHS, Western Cape, South Africa.All 125 MOs working in facilities associated with the Stellenbosch University Family Physician Research Network (SUFPREN) were included in the survey. A questionnaire measured the prevalence of key factors that might be associated with retention (staying >4 years) and included the Satisfaction of Employees in Health Care (SEHC) tool and Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS). Data were collected in Research Electronic Data Capture (REDCap) and analysed in the Statistical Package for Social Sciences (SPSS).Ninety-five MOs completed the survey. The overall rating of the facility (P = 0.001), age (P = 0.004), seniority (P = 0.015), career plans (P<0.001), and intention to stay in the public sector (P<0.001) were associated with retention. More personal factors such as social support (P = 0.007), educational opportunities for children (P = 0.002), and staying with one's partner (P = 0.036) were also associated with retention. Sex, rural versus urban location, district hospital versus primary care facility, overtime, remuneration, and additional rural allowance were not associated with retention.The overall rating of the facility was important and subsequent qualitative work has explored the underlying issues. These findings can guide strategies in the Western Cape and similar settings to retain MOs in the DHS.

International graduates’ experiences of reflection in postgraduate training: a cross-sectional survey

Abstract: Reflection is a key component of postgraduate training in general practice. International medical graduates (IMG) are thought to be less familiar with reflection, with international medical schools favouring more didactic methods of education.To explore IMGs' experiences of reflection prior to and during GP training and the support available for developing skills in reflection.A cross sectional survey was sent to IMGs undertaking GP training in 12 of the 14 UK regions, from March to April 2021.A pre-tested self-administered online questionnaire was used to collect data on experiences of reflection, both prior to and during GP training, and the support available for developing skills in reflection.In total, 485 of 3413 IMG trainees completed the questionnaire (14.2% response rate, representative of national demographics). Of these, 79.8% of participants reported no experience of reflection as an undergraduate and 36.9% reported no formal training in reflection during GP training. The majority (69.7%) of participants agreed that reflection was beneficial for their training and 58.3% reported that the best support in reflection came from their supervisors. Experience of reflection, opinions on the benefits, and best sources of support all varied by where the responders' primary medical qualification (PMQ) was obtained (all P values<0.01).Most IMGs have not experienced reflection prior to commencing UK GP training. There is diversity in experience and culture within this group that must be considered when tailoring educational interventions to support IMGs in their transition to UK GP training.

The nature and prevalence of threats to medical student placement capacity in primary care: a survey of East of England GP practices

Abstract: GP practices deliver vital medical student teaching in the face of increasingly challenging circumstances.To understand the nature and scale of threats to medical student teaching capacity in primary care.An electronic survey of a predefined population of 120 East of England GP practices that host medical student placements.The survey was completed on behalf of the practice by the GP lead for medical student teaching. They were asked to pick (from a list of 16) the four main challenges they faced delivering medical student teaching placements, then explain their selection and suggest solutions. Thematic analysis of free-text responses was undertaken from an activity theory perspective.Responses were received from 114 of the 120 practices in the study population (95% response rate). The most commonly selected challenges to delivering placements were clinical/practice workload (picked by 92 practices), and lack of space in the practice (picked by 63 practices). Thematic analysis produced a model whereby a practice's decision to continue hosting students was influenced by level of motivation and burden of teaching, but only if a certain level of resource enablement is present. Analysis of free-text responses suggested that space pressures were perceived as being exacerbated by the need to accommodate more clinicians, especially advanced practitioners employed by primary care networks (PCNs) under the additional roles reimbursement scheme (ARRS).This study provides much-needed quantitative evidence to support the view that lack of space in GP premises is a major threat to the future of undergraduate general practice.

High rates of anorectal chlamydia in women: a cross-sectional study in general practice

Abstract: Background Genital and anorectal Chlamydia trachomatis (CT) frequently present together in sexually transmitted infection (STI) clinics. Aim To investigate the prevalence of co-occurrent genital and anorectal chlamydia infection, and to study whether sexual behaviour is associated with anorectal infection. Design & setting A cross-sectional study in general practices in the north of the Netherlands. Method Women attending general practice with an indication for genital chlamydia testing were included and asked to complete a structured questionnaire on sexual behaviour. Anorectal infection prevalence was compared according to testing indications: standard versus experimental (based on questionnaire answers). Variables associated with anorectal chlamydia were analysed by univariate and multivariate logistic regression analyses. Results Data could be analysed for 497 of 515 women included. Overall, 17.8% ( n = 87/490) were positive for CT; of these, 72.4% ( n = 63/87) had co-occurrent genital and anorectal infection, 13.8% ( n = 12/87) had genital infection only, and 12.6% ( n = 11/87) had anorectal infection only. Rectal infection was missed in 69.3% of cases using the standard indication alone, while adding the sexual history still missed 20.0%. Age was the only variable significantly associated with anorectal infection. Conclusion The prevalence of anorectal disease is high among women who visit their GP with an indication for genital CT testing. Many anorectal infections are missed despite taking comprehensive sexual histories, meaning that standard treatment of genital infection with azithromycin may result in rectal persistence. Performing anorectal testing in all women with an indication for genital CT testing is, therefore, recommended.

Workload effects of online consultation implementation from a Job-Characteristics model perspective

Abstract: Online consultation (OC) was previously promoted by the NHS to solve primary care workload challenges. Its implementation was sped up during the COVID-19 pandemic. Workload effects are widely debated. Using a job design perspective may enhance understandings of workload effect.To qualitatively interrogate the workload experiences of primary care staff involved in OC implementation, using the Job Characteristics Model (JCM) to enable the following: a clearer understanding of the primary care staff psychological experiences; and recommendations informing the design of digital implementations and continued use.A qualitative interview study of GP practices using OC within South West England.Thirteen participants representing seven practices completed JCM-based semi-structured telephone interviews. An abductive theoretically driven thematic analysis was completed.Participants experienced different tasks pre- and post-implementation of OC, and adapted differently to them. Differences included the following: contact modality change, some administrative staff felt removed from patient contact; and in perceived autonomy, some GPs valued increased workload control. Variation in workload experience was affected by job role and practice context, and the form of and rationale for implementation. Use of a psychological model (the JCM) allowed clearer consideration of the effects of change, as well as OC on workload.Psychological theory may be helpful in interpreting workload effects of technology implementation such as OC. Designing change to include consideration of technology effects, psychological experiences, differences across roles, and individual and practice contexts may be important for technology implementation and evaluation of its workload effects.