BJGP Open

Objective: To identify patient, clinician, therapist and service priorities for a health-literacy intervention combining patient education with patient-reported outcome measure (PROM) feedback in routine hand surgery and hand therapy. Methods: A qualitative co-design study was undertaken across public and private hand-care contexts in New South Wales, Australia. Twelve stakeholders participated: five consumers, three hand surgeons, one hand therapist and three administrative/managerial staff. Individual interviews plus a clinician group discussion were conducted. Data were collected in March 2026, audio-recorded, transcribed verbatim and de-identified. General inductive thematic analysis was undertaken in NVivo by one researcher, with final themes reviewed by co-investigators. Results: Four themes guided intervention design: (1) providing information is not enough, it must be understood, retained and reinforced; (2) patients need a practical roadmap of diagnosis, treatment, recovery and rehabilitation; (3) education should be multimodal, reusable and adaptable to individual needs; and (4) PROMs should improve the clinical conversation rather than become another burden. Participants supported brief, accessible PROMs and visual feedback over time, but views differed on comparison with other patients because benchmarking could either reassure or create anxiety and unrealistic expectations. Conclusion: Health-literate hand care requires more than readable leaflets. It requires repeated, practical and adaptable communication across the care pathway, with PROM feedback embedded in patient-clinician conversations. Practice implications: Hand services should pair standardized core education with flexible delivery and use brief PROMs as conversation tools. Longitudinal displays may support monitoring and shared decisions, while group comparisons should be optional and carefully explained.

BackgroundCommunication issues across the primary-secondary care interface are considered one of the most important challenges in improving patient safety in primary care in the UK. Teleconferencing offers a potential means of improving communication during referrals but is largely unevaluated. AimTo explore teleconferencing as an alternative to written Advice and Guidance (A&G) referrals for neurology cases, by assessing its impact on GP-specialist communication and relationships, and exploring implications for patient care. Design and SettingA qualitative case study of a primary care network (PCN) and a secondary care centre in East Anglia. Methods18 clinicians and 10 other stakeholders were interviewed. Observations of teleconferences and a focus group with five PCN staff provided additional data. Data collection and analysis were guided by the Consolidated Framework for Implementation Research and Reflexive Thematic Analysis. ResultsAdvantages of teleconferencing identified by participants included greater clinician satisfaction, mutual educational value, streamlined patient journeys and continuity of care. Teleconferences were also seen to build GP-specialist relationships and reduce unnecessary outpatient referrals. Perceived issues included time constraints, clinical governance and funding sustainability; teleconferences were not seen as appropriate for all referrals. Overall, participants welcomed the teleconference approach but stressed the need to robustly assess its cost-effectiveness and replicability in other settings. ConclusionTeleconferencing is a potentially promising alternative to written A&G referrals and was perceived by participants to help build GP-specialist relationships. However, further studies are needed to assess clinical effectiveness and costs, and to guide future development and implementation. How this fits inO_ST_ABSWhat is known?C_ST_ABSReferral interventions involving direct GP-specialist dialogue can enhance referral quality, reduce outpatient referrals and improve GP-specialist relationships, with some demonstrating improved clinical outcomes. However, they often face sustainability challenges, and their cost-effectiveness and mechanisms of impact require further assessment. What does this study add?This qualitative study identifies key mechanisms through which virtual GP-specialist dialogue may lead to downstream benefits: enabling shared decision-making and delivering consultant-level care closer to home; empowering GPs to manage complex cases; and reducing overall workload across primary and secondary care systems. The programme theory developed can be used to guide future intervention design, implementation and evaluation.

BackgroundIn England and Wales, the Quality and Outcomes Framework (QOF) financially rewards GP practices for long-term conditions management, including completion of annual dementia reviews. There is limited evidence about how this works in practice and whether it meets patients and carers needs. MethodsData from five qualitative datasets were integrated and analysed thematically. Data comprised interviews, focus groups, and observations with 209 participants, including commissioners, managers and frontline staff in dementia services; people with dementia; carers; and policy experts. FindingsFour main themes were developed: (i) perceived benefits of annual review; (ii) variability and (in)visibility of annual review; (iii) logistics; and (iv) external influences and constraints. Variability in both the completion and quality of QOF annual dementia reviews was attributed by some to limited nuance in the current QOF dementia indicator. Many patients and carers were unaware that an annual dementia review had occurred. Participants suggested that many GPs lack the required competencies and/or capacity for successful dementia reviews. ConclusionsWork is urgently needed to improve the quality of annual dementia reviews. Potential strategies include changing the financial reimbursement to reflect both quality and quantity, so the review is tailored to the needs of the individual and their family; the creation of standardised templates; collaborative working within primary care and across sectors; and integrating dementia reviews into other long-term conditions. Key pointsO_LIQOF annual dementia reviews are a key opportunity for providing support for people with dementia in England and Wales C_LIO_LICurrent provision of annual reviews varies both in completion rates and quality C_LIO_LIStrategies for improvement include improving quality indicators, implementing standardised templates, and improving primary care capacity and capability to carry out reviews C_LI

BackgroundMany people experience long waiting times for hip and knee replacement surgery, negatively impacting physical conditioning and quality of life, and therefore need evidence-informed strategies to support them while they are waiting. ObjectiveTo develop consensus-based recommendations for supporting people waiting for hip or knee replacement in Scotland. DesignThree-round online modified Delphi study involving 17 people with experience of waiting for hip or knee replacement and 30 professionals involved in supporting them. MethodsTwo rounds of online survey and one online workshop. Participants rated agreement with 113 (round 1), 40 (round 2) and 20 (round 3) statements on a 5-point Likert scale, with consensus based on [≥]70% agreement. Items were modified and added in subsequent rounds based on content analysis of participant comments. The final recommendations represent items that reached consensus in both participant groups after 3 rounds. Results47 participants took part in round 1 (17 patients, 30 professionals), 41 in round 2 (13 patients, 28 professionals) and 23 in round 3 (8 patients, 15 professionals). Eighty-two of 113 statements reached consensus in round one, 20 of 40 in round two and 6 of 20 in round 3. The final recommendations comprise 108 statements relating to: preoperative education; patient optimisation; other interventions to support people waiting; and, strategies to support people waiting a long time for surgery. ConclusionsThese findings are an important step towards developing best practice guidance for supporting people waiting for hip and knee replacement in Scotland.

Background Effective communication during consultations is facilitated by clinical empathy and realistic optimism, and can enhance patient satisfaction with care, alleviate symptoms, and improve quality of life. However, primary care systems are under significant strain and changing rapidly, which may affect practitioners' ability to communicate empathically and convey realistic optimism, with implications for the patient-practitioner relationship and patient outcomes. Understanding patients' perspectives of healthcare communication in the current clinical context is therefore important. We aimed to explore patients' experiences and perceptions of communication in UK primary care consultations, focussing on the communication of clinical empathy and realistic optimism. Methods A qualitative interview study was conducted as part of a multi-centre cluster-randomised trial of EMPathicO, a brief e-learning package for Primary Care Practitioners (PCPs) on communicating clinical empathy and realistic optimism. Participants were not aware whether their general practice had access to EMPathicO or not. Interviews were conducted within 7-14 days of participants' consultations, explored their views and experiences of clinical empathy and realistic optimism, and were transcribed verbatim. Interviews were analysed using Ritchie and Spencer's Framework Method. Results We conducted semi-structured audio-recorded qualitative telephone interviews with 71 participants from 29 primary care practices taking part in the EMPathicO trial. Following comprehensive mapping of data to the framework derived following initial analysis, four themes were agreed. Overall, most participants described positive empathic consultations with their PCPs, however, participants' experiences were shaped by wider systemic and contextual factors. They described a stretched and inefficient primary care system impacting empathy and optimism; the impact of PCP 'preparedness' as a marker for empathy; how consultation modality (i.e. in-person or telephone) shaped perceptions of empathy, and how PCPs sharing next steps in participants' treatment and management could foster realistic optimism. Conclusions While clinical empathy and realistic optimism may be experienced by patients during consultations with practitioners, the wider contextual challenges of accessing and navigating primary care systems can threaten overall perceptions of feeling cared for. Future primary care policy and workforce training must consider these system pressures to preserve effective communication in consultations and positive patient-practitioner encounters.

IntroductionDigital diabetes management systems have the potential to deliver cost-effective, flexible self-management support to patients with type 2 diabetes. DiabetesMyWay (DMW) is a platform for an open access website that aims to support diabetes self-management and provide patients with access to their care records. We present a case study focusing on a project involving patients across the large urban area of Greater Manchester (GM). MethodsInterviews were undertaken with 8 members of the project team and 3 patients using the platform. Data were analysed thematically using the template analysis approach. ResultsThree themes are presented: Complex approvals, permissions and access across multiple organisations and systems; Capacity challenges in primary care settings; Ongoing support for the project. Implementation and evaluation of GMDMW involved navigating data sharing systems and regulations for complex private and public sector organisations and these impacted on the electronic data sharing necessary for the DMW platform to work as intended. Participants felt that the complexities associated with merging different systems, operated by different organisations, with different data controllers and data owners were greater than anticipated. DiscussionThe complexity, number of organisations and levels of governance involved in implementing and evaluating GMDMW were barriers to implementation and evaluation. This reflects inherent problems around mobilising innovation in the NHS. Our findings can help the development and evaluation electronic interventions to improve health to navigate this complex research landscape and ensure that patients can access the most innovative and effective ways to support their health. (245/250 words) Author summaryDigital health interventions and Public Private Partnerships for innovation in the NHS are on the rise and in order to establish efficacy, these need to be evaluated. Often, this research and evaluation is carried out by Universities. However, challenges around navigating governance across these complex, multiple organisations exist where there is a need to share data and collaborate across systems effectively. Here, we describe the many unexpected challenges and solutions to effective data sharing reported by professionals and patients involved in the delivery and evaluation of a UK-based NHS/ private sector collaboration to provide a digital platform to support self-management of diabetes.

Background The incidence of post-operative periprosthetic femoral fractures (POPFFs) is increasing. However, specific clinical guidance relating to patient management does not exist, resulting in variations in care and outcomes. This study aimed to elicit and synthesise expert knowledge in POPFF service delivery and explore views on variations in service provision and the factors influencing these. Methods Semi-structured interviews were undertaken with healthcare professionals with expertise in POPFF care from England and Wales to explore current practices, challenges, service variations and perceived future opportunities. Participants were identified through specialist research and clinical networks for POPFF and hip fracture care, authors of key publications on the subject, national leads for POPFF/hip fracture networks, and research team contacts. Interviews were analysed using thematic analysis. Results Ten interviews were undertaken with experts in POPFF services across a range of professional roles. Four themes were identified: conceptualisation of POPFF (by different professional groups and in different service settings) and understanding of POPFF patient needs; sources of variation in management and care of POPFF patients; service model rationales, advantages and disadvantages; and potential strategies to improve POPFF care. Conclusion When designing POPFF services, we suggest that four key areas need consideration: the extent to which POPFF patients are a distinct group with particular care needs; the necessity for and consequences of patient transfer between wards and hospitals; the resourcing of extensive multidisciplinary support for POPFF patients; and the need for national initiatives to encourage service developments. These findings should form the basis of future clinical guidance. Sensitivity to contextual factors driving variation in services is needed to ultimately improve care for POPFF patients.

BackgroundThe Community and Hospital cAre Bundle to improve the medical treatment of cLaudIcation and critical limb iSchaemia (CHABLIS) study is a prospective mixed-methods study across NHS hospitals and primary care networks, which aims to determine the feasibility of using a complex intervention in the form of a care bundle, consisting of checklists, leaflets and letters, called the LEGS intervention (LEaflet Gp letter Structured checklist), to improve the care of patients with peripheral arterial disease (PAD). The aim of this qualitative study was to gain an understanding of the acceptability of the provision and delivery of the LEGS intervention, by patients, general practitioners and secondary care clinicians. Engaging stakeholders in these conversations provides insights for future intervention refinement, uptake and implementation. MethodsThis qualitative study was embedded within the CHABLIS study. Twenty-five semi-structured telephone interviews were conducted with i) patients who had received the intervention (n=11), ii) secondary care clinicians responsible for delivering the intervention (n=8), and iii) general practitioners (n=6). Data were initially analysed using inductive descriptive thematic analysis. The consolidated framework for implementation research was then used as a matrix to explore patterns in the data and to map connections between the three participant groups. Lastly, interpretive analysis allowed for refining, and a final coding frame was developed. ResultsFour overarching themes were identified: i) The potential to make a difference, ii) A solution to address the gap in no mans land, iii), Prioritising and making it happen and iv) Personalised information and supportive conversations for taking on the advice. The intervention was viewed as an opportunity to meet patient needs, and to develop shared primary and secondary care working practices. The impetus for prioritising and delivering the intervention was further driven by its flexibility and adaptability to be tailored to the individual and to the environment. ConclusionsThe LEGS intervention can be tailored for use at early and late stages of PAD, can be provided across primary and secondary care settings, and provides an opportunity to promote shared working across the primary-secondary care interface. Contributions to the literatureO_LIPrimary and secondary care providers acknowledged the need for an intervention to support them to deliver guideline-based PAD treatment, and to target the intervention earlier in the PAD treatment pathway. C_LIO_LIA gap was identified in terms of support for patients and providers between the time of diagnosis of early-stage PAD (e.g., claudication) and a subsequent potential diagnosis of advanced PAD. The LEGS intervention can be used to fill this gap by enabling providers to support patients to receive help, education, support, or appropriate medication to address their condition. C_LIO_LIPatient-provider interactions that promote shared decision-making and that support patient preference are also important determinants in the success of implementation. C_LI

BackgroundDementia affects over 57 million people worldwide. UK and international policy position personalised, conversation-based care planning as central to post-diagnostic support. However, delivery in primary care is inconsistent, and many practitioners lack dementia-specific communication training. Existing evidence focuses on single roles or settings, leaving a gap in understanding how communication operates across the primary care workforce. AimsTo identify what helps and hinders effective communication for integrated dementia care planning and determine the support and training needs of the wider primary care workforce. MethodsO_LISemi-structured interviews - 11 people with dementia, 13 family carers, and 19 primary care practitioners from diverse roles, exploring experiences of care planning conversations C_LIO_LIReflexive thematic analysis C_LI ResultsThree themes were developed, progressing from micro-level communication practices (Theme 1: Beyond the tick-box), through triadic dynamics (Theme 2: Balancing voices in the conversation), to organisational influences (Theme 3: From silos to meaningful shared care planning). Time and Conversation as intervention cut across all themes, shaping trust and disclosure. Participants reported reliance on tick box approaches, inconsistent preparation, and uncertainty about care plan purpose and ownership. Non-clinical roles were commonly viewed as well placed to support meaningful conversations, but were often described as constrained by unclear remit and weak integration. ConclusionsA persistent gap remains between policy ambitions and everyday practice. Time-pressured, checklist-driven encounters and fragmented systems undermine shared decision-making. The expanded primary care workforce offers untapped potential to address these gaps, but this requires clearer roles, formal integration, and targeted investment in communicative skills.

BackgroundVarious approaches to advance care planning are being used, also for persons with dementia and their care partners. Two contrasting approaches involve a highly scripted, predominantly medical approach to decide on specific treatments in advance versus a more flexible psychosocial, coping-based approach comprising global care goal setting. ObjectiveTo assess situations in which either approach is preferred in dementia from the perspective of general practitioners. MethodsWe interviewed thirteen practitioners participating in the Dutch CONT-END study; seven were trained in the medical approach and six were trained in the psychosocial approach. We explained the other approach during the interview. Twelve other practitioners were interviewed after viewing video vignettes of the two approaches shown in random order. Inductive qualitative content analyses was guided by the aim to elucidate for whom and when an approach was preferred. ResultsFour attributes distinguished situations in which either approach is preferred: understanding, trust, readiness and momentum. For the medical approach, understanding, trust, and readiness on part of person and care partner were prerequisites for optimal momentum, which, however could also be triggered by urgent medical reasons. In contrast, the psychosocial approach would help understand the person, foster trust and create readiness from a first conversation. Without a clear trigger, however, momentum would need to be created. ConclusionsSkill in employing various approaches to ACP conversations each with specific benefits could help tailor ACP to the individual and their situation. Further theoretical and empirical research including in other populations and settings may inform person-centred ACP. Key PointsA medical versus a more psychosocial approach to advance care planning (ACP) in dementia can be typified by contrasts within four attributes: understanding, trust, readiness and momentum. Although both approaches are appropriate in itself, either is superior depending on the situation of the persons involved, and the psychosocial approach may be particularly suitable for a first conversation initiated by a professional caregiver. Further theoretical clarification and empirical research could enhance and refine ACP training programs and inform person-centred ACP in more diverse practices and populations.

PurposePeople living with MLTCs attending consultations in primary care frequently have unmet social care needs (SCNs), which can be challenging to identify and address. Artificial intelligence (AI) derived clusters could help to identify patients at risk of SCNs. Understanding the views of people living with MLTCs and those involved in their care can help inform the design of effective interventions informed by AI-derived clusters to address SCNs. MethodsQualitative study using semi-structured online and telephone interviews with 24 people living with MLTCs and 20 people involved in the care of MLTCs. Interviews were analysed using Reflexive Thematic Analysis. ResultsPrimary care was viewed as an appropriate place to have conversations about SCNs. However, participants felt health care professionals lack capacity to have these conversations and to identify sources of support. AI was perceived as a tool that could potentially increase capacity for this but only when supplemented with effective, clinical conversations. Interventions harnessing AI should be brief, be easy to use and remain relevant over time, to ensure no additional burden on clinical capacity. Interventions must allow flexibility to be used by multidisciplinary teams within primary care, frame messages positively and facilitate conversations that remain patient centered. ConclusionOur findings suggest that AI-derived clusters to identify and support SCNs in primary care have perceived value, but there were some concerns including the need to consider personal context. AI derived clusters can be used as a tool to inform and prioritise effective clinical conversations. Conference names, dates and locations for any prior presentationsO_LIBritish Journal of General Practice Research Conference, March 2024, London. C_LIO_LISchool of Academic Primary Care Southwest Conference, March 2024. Cardiff. C_LIO_LIFaculty of Medicine Research Conference, June 2024. Southampton. C_LI

QuestionDo advanced practice physiotherapists succeed in conducting shared decision-making (SDM)? DesignA prospective cross-sectional observational study of patients with musculoskeletal pain and their perceptions of SDM measured using the CollaboRATE instrument. Written feedback was collected after consultation to gain understanding of patients experiences of their consultations. ParticipantsChronic pain patients (n = 5123) diagnosed with either upper limb (n = 1230, 24%), lower limb ((n = 3044, 59.4%), or foot/ankle pain (n = 849, 16.6%) consulting an advanced practice physiotherapist across two hospitals in the UK between January 2023 and December 2024. ResultsMean total CollaboRATE scores across all items were 11.9 ({+/-}0.53). Overall, 4906 (95.8%) of participants gave the maximum CollaboRATE score of 12. No significant differences were observed between sites (p < .001). A regression model including site and pain category was statistically significant but explained minimal variance (R{superscript 2} = 0.004), suggesting other factors contribute more substantially to SDM perceptions. From 949 patient responses, our qualitative analysis revealed a generally positive SDM experience with advanced practice physiotherapists. Feedback clustered around five key themes: 1) feeling valued and involved, 2) communication, expertise, and clarity, 3) compassionate and professional care, 4) efficient organisation, and 5) negative experiences. ConclusionAdvanced practice physiotherapists were largely successful in facilitating SDM, with patients reporting positive experiences across both clinical sites. While quantitative findings showed minimal influence of site or pain category, qualitative insights highlighted the importance of clinician communication, empathy, and involvement of patients in care planning as key drivers of SDM perceptions.

Several studies have shown that using language that is most suitable for the patient is essential for effective communication in healthcare. Using a patients second language during health consultations can negatively impact a patient, causing delays in treatment and misdiagnosis. In Wales both Welsh and English have equal status in public sector organisations, however, independent primary care providers such as General Practices (GPs), do not need to comply with all the Welsh Language Standards. Thus, there is inconsistency in the availability of bilingual healthcare provision. This mixed methods study used a focus group and a survey of the Welsh speaking general population (361 participants) to gauge awareness of the Welsh Language Standards and collect experiences of bilingual healthcare, concentrating on GPs. The data underwent both qualitative thematic and quantitative analysis and revealed low awareness of the Welsh Language Standards (27%). Overall, respondents felt that their need to use Welsh is not taken seriously, with 71% having never been offered a Welsh consultation. 57% that have an English medium doctor reported that they would feel more comfortable having their consultations in Welsh. 32% of respondents from higher percentage Welsh speaking areas have felt restricted by their inability to communicate in their first language during GP appointments. There was overwhelming support for recording a patients preferred language on health records. The results suggest that the Welsh speaking public both want and need Welsh provision in primary care. However, there is a need to review primary care policies to facilitate a more effective roll out of an active offer of first language healthcare in Wales.

BackgroundEarlier identification and registration of people in the last year of life improves care quality and outcomes in general practice. However, there is little evidence on patients who subsequently no longer require end-of-life registration, nor on the safety or outcomes of de-registration following clinical review. AimTo determine the prevalence, safety, and prognostic validity of GP-led removal from the end-of-life register (EOL_R) using a systematic digital review process. Design and SettingObservational cohort study in eight practices in Wolverhampton, UK, using a whole-population integrated primary and secondary care dataset. MethodAll adults on the EOL_R were systematically reviewed using a digital end-of-life pathway (PRADA) incorporating robotic process analysis of recognised end-of-life care markers. GPs recorded a binary decision to retain or remove patients from the register. Mortality outcomes were compared with those retained on the EOL_R, a tightly propensity-matched cohort not on the register, and the residual general population over 15 months. ResultsOf 422 registered patients, 33 (7.8%) were removed following GP assessment. One-year survival in the removed group was statistically indistinguishable from the propensity-matched control cohort, and survival was significantly higher versus those retained on the EOL_R (60.4%, p<0.001). Removal demonstrated a negative predictive value for mortality of 90.9%. ConclusionGP-led removal from the end-of-life register can be undertaken safely and identifies a distinct group with substantially better prognosis. Digital systems that support systematic review, documentation, and follow-up should be incorporated into routine practice and reflected in national guidance and the Quality and Outcomes Framework. Statement boxesO_ST_ABSWhat is knownC_ST_ABSEarlier identification and registration of people in the last year of life improves care coordination and outcomes. However, little is known about patients who subsequently no longer require end-of-life registration, or whether removal following clinical review is associated with adverse outcomes. What this study addsIn a whole-population primary care cohort, General Practitioners removed 33 patients (7.8% of those registered) from the end-of-life register following structured clinical review. One-year survival in this group was equivalent to a tightly matched cohort not on the register, and survival was substantially higher than among patients retained on the register. A simple robotic based review process can prompt systematic reassessment, capture GP clinical judgement, and enable prospective monitoring following removal. ImplicationsEnd-of-life registration should be treated as a dynamic process requiring ongoing clinical review. Digital systems can support safe removal from registers by documenting decisions and embedding follow-up for patients whose prognosis remains uncertain. Evidence-based guidance and governance processes for a review process are needed to ensure people are not retained on registers unnecessarily. How this fits inEnd-of-life registers are intended to support proactive care for people in their last year of life, yet there is little evidence about patients who later stabilise and may no longer require registration. In eight UK practices, a systematic GP review supported by a digital end-of-life pathway identified a small but clinically important group suitable for removal, without adverse mortality outcomes. Beyond improving register accuracy, structured review creates opportunities for meaningful dialogue with patients, shared reassessment of care goals, and appropriate de-escalation of end-of-life labelling. Embedding routine, structured review with documented decisions and follow-up may also reduce unnecessary clinical workload and strengthen governance in primary care. Novelty StatementSystematic GP review of end-of-life registers, as stipulated in GMC guidance, is rarely evaluated. We propose a digitally driven, systematic and dynamic clinical-governance-led approach to register review.

ObjectivesUK carer assessments, in primary and social care, intend to discover what carers need in their caring roles and more widely. Evidence points to these not being configured sufficiently around carers of people with dementia, with potentially their breadth of needs not being recognised. We evaluated the extent of agreement, between carers of people with dementia, primary care, and social care professionals, on their recommendations from assessing carers needs in a range of circumstances. It is intended for findings to be taken forward as recommendations for policy and practice. MethodsComparison of judgements, between carers, primary and social care professionals, on whether real-life circumstances in 9 anonymised case vignettes necessitated a range of 14 services to support carers appropriately. Participants were 6 carers of people with dementia, 7 primary care staff, and 2 social care staff. We presented participants with each vignette and asked them to make binary judgements of whether they would recommend a range of services in each case. Percentage agreement and Fleiss kappa coefficients measured the level of agreement amongst multiple carers, primary and social care staff and overall. These agreements were then compared. ResultsCarers agreed in their judgements more than primary or social care professionals. The overall level of agreement from judgements made by all participants, however, was slight with variability between participant groups and overall. The need for First Language Support in some cases was recognised, an improvement from previous evidence. ConclusionsCase vignettes are useful for investigating judgements concerning these carers needs, so raising issues for policy and practice. It is essential for carer assessments to be more reliable in recommending services based on need to ensure less variability, depending on assessor and carers circumstances.

IntroductionThe rapidly increasing prevalence of long-COVID (LC), the multisystem complexity of the condition and high patient symptom burden, necessitated an immediate need to develop new clinics for assessment and management. This article reports on the rapid implementation of a reactive and responsive LC care pathway. We mapped patients journey through this pathway, identifying the services that were activated according to prevalent symptoms, and assessed the barriers and facilitators to its implementation and delivery, from the perspective of health care professionals (HCPs) and LC patients using the Theoretical Domains Framework (TDF). MethodsMixed methods study, including retrospective quantitative cross-sectional analysis of patient data and semi-structured qualitative interviews. One hundred and sixteen patients who attended long-COVID clinic in Hertfordshire, UK, in the first 5 months of its existence, consented for their data to be analysed for the quantitative study. Six HCPs and five patients participated in semi-structured interviews. ResultsPatients were referred into the service an average of 5.75 months post initial COVID-19 infection. 82% of patients required onward referral to other HCPs, most commonly pulmonary rehabilitation, chronic fatigue specialists, and the specialist COVID-19 Rehab general practitioner embedded within the service. Patients reported having rehabilitation needs, moderate depression and anxiety, and difficulties performing usual activities of daily living at point of care. The TDF domains most relevant to the implementation of the LC pathway were beliefs about capabilities, environmental context and resources, knowledge, and reinforcement. DiscussionOur study provides novel insight into the development of a reactive multidisciplinary care pathway. Key drivers for successful implementation of LC services were identified, such as leadership, multidisciplinary teamwork, transferable skills, and knowledge exchange. Barriers to rapid set up of the service included funding constraints and the rapid evolution of an emergency context.

BackgroundThe COVID-19 pandemic significantly accelerated the adoption of telemedicine, but it also exposed gaps in effective remote clinical assessment, particularly for medically vulnerable patients in rural areas. The ORCHARD intervention aimed to address this by providing patients with a Medical Self-Assessment Box to enable self-reporting of vital signs during remote consultations. MethodsA single-centre randomised mixed-methods feasibility trial recruited medically vulnerable patients from a rural general practice in Northeast Scotland. Participants in intervention group received a home medical equipment box for use during telemedicine consultations over six months. Patients and GPs were interviewed and transcripts were analysed using Framework Analysis. ResultsTwelve (15%) of 82 eligible invited patients enrolled. Six each were allocated to intervention and control group. 50%(n=3)patients in intervention group used equipment in 45%(5 of 11)teleconsultations and rated it helpful in all 5 uses (100%). The intervention group had 18% fewer primary care contacts than controls. All remote consultations were by telephone. Framework Analysis of patient interviews identified facilitators such as ease of use, improved triage access, reassurance, and barriers related to GP non-engagement and written instructions. GP interviews identified clinical value in patient-generated readings, alongside concerns regarding workload and patient over-monitoring. ConclusionsHalf of intervention participants used the medical-equipment box during remote consultations, all finding it useful, though frequency of use varied among particpants.A randomised controlled trial to evaluate the effectiveness of the Medical Self-Assessment Box for optimising remote consulting in medically vulnerable rural patients is feasible.Prior to a definitive trial refinements are recommended to patient labelling, GP engagement, and training materials.

BackgroundThe NHS 111 service triages over 16,650,745 calls per year and approximately 48% of callers are triaged to a primary care disposition, such as a telephone appointment with a general practitioner (GP). However, there has been little assessment of the ability of primary care services to meet this demand. If a timely service cannot be provided to patients, it could result in patients calling 999 or attending emergency departments (ED) instead. This study aimed to explore the patient journey for callers who were triaged to a primary care disposition, and the ability of primary care services to meet this demand. MethodsWe obtained routine, retrospective data from the Connected Yorkshire research database, and identified all 111 calls between the 1st January 2021 and 31st December 2021 for callers registered with a GP in the Bradford or Airedale region of West Yorkshire, who were triaged to a primary care disposition. Subsequent healthcare system access (111, 999, primary and secondary care) in the 72 hours following the index 111 call was identified, and a descriptive analysis of the healthcare trajectory of patients was undertaken. ResultsThere were 56,102 index 111 calls, and a primary care service was the first interaction in 26,690/56,102 (47.6%) of cases, with 15,470/26,690 (58%) commenced within the specified triage time frame. Calls to 999 were higher in the cohort who had no prior contact with primary care (58% vs 42%) as were ED attendances (58.2% vs 41.8), although the proportion of avoidable ED attendances was similar (10.5% vs 11.8%). ConclusionLess than half of 111 callers triaged to a primary care disposition make contact with a primary care service, and even when they do, call triage time frames are frequently not met, suggesting that current primary care provision cannot meet the demand from 111.

IntroductionAccess to specialist care in the Netherlands requires a general practitioner (GP) referral, yet referrals to secondary care keep rising. Triage has been proposed to manage this demand and may be relevant for internal medicine, which addresses diverse and increasingly complex conditions. This study aimed to identify the internal medicine healthcare needs which were redirected to the GP after triage and to explore the factors driving GP referral behaviour. MethodsThis multi-method study combined quantitative referral data with qualitative insights from GP focus groups. Data were extracted from a hospital in an urban region, including adults with non-acute complaints referred for outpatient consultation to internal medicine between August 2019 and July 2021. Referrals were triaged for appropriateness and redirected where possible. Focus groups explored GPs perspectives on referral practices. ResultsOf 5,826 referrals triaged, 998 (17%) were redirected to the GP with advice and guidance. Endocrinology accounted for 35% of redirected cases, followed by nephrology (8.6%). Focus groups revealed underlying drivers of referral behaviour, identifying four themes: medical factors; GP-related factors, including professional uncertainty and autonomy; patient-related factors; and external factors, such as contextual and regulatory influences. ConclusionThis study demonstrates that triage is a feasible strategy for managing referral volumes, particularly within domains such as endocrinology where many medical problems can be managed in primary care. However, referrals are shaped by more than clinical need, reflecting uncertainty, emotional considerations, patient expectations and systemic factors. Strengthened collaboration between primary and secondary care, alongside pre-referral consultation strategies, is essential to ensure appropriate, high-quality patient care.

Background Post-infection conditions (PICs), such as Long Covid, are associated with heterogeneous, fluctuating symptoms that profoundly affect daily functioning. Despite moderate-certainty evidence from the NIHR-funded LISTEN trial (COV-LT2-0009) that personalised self management support improves outcomes and may reduce societal and economic impacts of Long Covid, many people living with PICs still receive condition-specific services, generic advice, or stand-alone digital tools that do not address their complex needs. Aim To map care approaches in general practice and synthesise UK evidence for PIC management. Design and setting Scoping review and online survey. Method A two-phase study was conducted: (1) a scoping review of UK evidence on PIC management in general practice; and (2) a supplementary online survey of practitioners working in UK general practice to provide contextual insights. Results The scoping review identified 32 studies focused on Long Covid. One study included a comparator group (ME/CFS). Study populations were predominantly white ethnicity and female. Evidence for non-Covid PICs in UK general practice was largely absent. The supplementary survey (n=46) provided preliminary practice-level insights. Healthcare practitioners reported varied PIC presentations, diagnostic uncertainty, limited referral pathways, inequitable access, and low confidence in managing PICs. Conclusion Evidence informing PIC management in UK general practice remains predominantly Long Covid-focused and may not reflect the range of PICs encountered in practice. While survey findings are preliminary and require confirmation in larger samples, they highlight uncertainty around PIC management. Further research is needed to evaluate whether existing Long Covid pathways should be expanded or complemented by broader PIC models. Keywords general practice; Long Covid; self-management; post-viral syndromes