BJGP Open

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

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.

BackgroundPhysician specialists (PS) are often the type of healthcare provider initially contacted by an individual with low back pain (LBP). LBP clinical practice guidelines (CPG) recommend a stepped approach to management with an emphasis on first-line non-pharmaceutical and non-interventional services. ObjectiveExamine the association between the incorporation of CPG recommended first-line services, exposure to second- and third-line services and total episode cost for individuals with non-surgical LBP initially contacting a PS. DesignRetrospective observational study with identical design to previous study focused on primary care physicians. Setting/PatientsNational sample of individuals with non-surgical LBP occurring in 2017-2019. MeasurementsIndependent variables were initial contact with a PS, and the timing of incorporation of five types of first-line services. Dependent measures included exposure to thirteen types of health care services and total episode cost. Results91,096 individuals were associated with 98,992 episodes of non-surgical LBP. 36.2% of the 33,277 PS initially contacted for an episode of LBP incorporated any first-line service at any time during an episode. A first-line service was provided in 24.0% of episodes with active care (19.5% of episodes), manual therapy (13.7%) and chiropractic manipulative therapy (6.5%) the most common. 7.3% of non-surgical LBP episodes included a first-line service within seven days of initial contact with a PS. These episodes were associated with a reduction in the use of prescription skeletal muscle relaxants (risk ratio (RR) 0.88) and opioids (RR 0.55), spinal injections (RR 0.84), and CT scans (RR 0.71), with no impact on the use of prescription NSAIDs, radiography, or MRI scans. First-line services were associated with an increase in total episode cost at any time of incorporation with chiropractic manipulation associated with the lowest cost increase. Younger individuals from zip codes with higher adjusted gross income were more likely to receive a first-line service in the first seven days of an episode. LimitationsAs a retrospective observational analysis of associations there are numerous potential confounders and limitations. ConclusionsFor individuals with non-surgical LBP PS provide second- or third-line services more frequently and earlier than CPG recommended first-line services. There is an opportunity to improve concordance with LBP CPGs for individuals with LBP initially contacting a PS.

ImportanceInappropriate prescribing and prescribing omissions are major drivers of healthcare-related harm. Medication review may help improve pharmacotherapy. ObjectiveTo study the effects of a primary care medication review intervention centered around an electronic clinical decision support system (eCDSS) on medication appropriateness and the number of prescribing omissions in older adults with multimorbidity and polypharmacy compared to usual care. Design and SettingThe "Optimising PharmacoTherapy In the multimorbid elderly in primary Care" (OPTICA) trial is a cluster randomized clinical trial conducted with general practitioners (GPs) and older multimorbid patients with polypharmacy in Swiss primary care settings, between January 2019 and February 2020. The 12-month follow-up was completed in February 2021. ParticipantsEligible patients had to be [≥]65 years of age with [≥]3 chronic conditions and [≥]5 long-term medications. InterventionThe intervention to optimize pharmacotherapy centered around an eCDSS compared to usual care. Main Outcomes and MeasuresThe two primary outcomes were the improvement in the Medication Appropriateness Index (MAI) and the Assessment of Underutilization (AOU) at 12 months. Secondary outcomes included the number of medications, number of falls and fractures and quality of life. ResultsIn 43 GP clusters, 323 patients were recruited (median age: 77 years (IQR: 73-83), 45% were female). 21 GPs with 160 patients were assigned to the intervention group and 22 GPs with 163 patients to the control group. On average, 1 recommendation to stop or start a medication were reported to be implemented per patient. At 12 months, there were no group differences in the improvement of medication appropriateness (Odds ratio (OR): 1.05; 95% confidence interval (CI): 0.59 to 1.87) nor the number of prescribing omissions (OR: 0.90; 95% CI: 0.41 to 1.96) in the intention-to-treat analysis. The per-protocol analysis showed no statistically significant group difference and there were no group differences in the secondary outcomes either. Conclusions and RelevanceIn this randomized trial of GPs and older adults, medication reviews based on the eCDSS reduced inappropriate prescriptions but did not lead to higher appropriateness of patients medications. The intervention could be safely delivered to patients without causing any detriment to their health. FundingSwiss National Science Foundation (407440_167465) Key points QuestionWhat is the effect of a GP administered medication review intervention supported by an electronic clinical decision support system on medication appropriateness in older patients with multimorbidity and polypharmacy? FindingsThis cluster randomized controlled trial included 43 general practitioners and 323 patients. At the end of the 12-month follow-up period, medication appropriateness and the number of prescribing omissions did not differ between patients who received the intervention and those who received usual care. MeaningThe intervention to optimize pharmacotherapy was feasible and safe to implement in primary care but did not improve overall medication appropriateness nor reduce the number of prescribing omissions.

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.

IntroductionAs health reforms move Ireland from a mixed public-private system toward universal healthcare, it is important to understand variations in prescribing practice for patients with differing health cover and socioeconomic status. This study aims to determine how prescribing patterns for patients aged [≥]65 years in primary care in Ireland differ between patients with public and private health cover. MethodsThis was an observational study using anonymised data collected as part of a larger study from 44 general practices in Ireland (2011-2018). Data were extracted from electronic records relating to demographics and prescribing for patients aged [≥]65 years. The cohort was divided between those with public health cover (via the General Medical Services (GMS) scheme) and those without. Standardised rates of prescribing were calculated for pre-specified drug classes. We also analysed the number of medications, polypharmacy, and trends over time between groups, using multilevel linear regression adjusting for age and sex. ResultsOverall, 42,456 individuals were included (56% female). Most were covered by the GMS scheme (62%, n=26,490). The rate of prescribing in all medication classes was higher for GMS patients compared to non-GMS patients, with the greatest difference in benzodiazepine anxiolytics. The mean number of unique medications prescribed to GMS patients was 10.9 (SD 5.9), and 8.1 (SD 5.8) for non-GMS patients. The number of unique medications prescribed to both GMS and non-GMS cohorts increased over time. The increase was steeper in the GMS group where the mean number of medications prescribed increased by 0.67 medications/year. The rate of increase was 0.13 (95%CI 0.13, 0.14) medications/year lower for non-GMS patients, a statistically significant difference. ConclusionOur study found a significantly larger number of medicines were prescribed to patients with public health cover, compared to those without. Increasing medication burden and polypharmacy among older adults may be accelerated for those of lower socioeconomic status. These findings may inform planning for moves towards universal health care, and this would provide an opportunity to evaluate the effect of expanding entitlement on prescribing and medicines use.

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.

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.

Introduction/AimsMultiple screening tools exist for identifying patients at risk of extended stay following lower limb arthroplasty. Use of these models at other hospital sites requires verification of appropriate data coverage and evidence of validity in a new population. The aim of this study was to adapt and assess 1) data compatibility, 2) discrimination, and 3) calibration of three published models for identifying patients at risk of an extended (5+ day) stay, or those likely to stay for the target 3 or fewer days following lower limb arthroplasty. MethodsRetrospective study, utilising a randomly selected (N=200 of a total 331 available in the electronic medical record) cohort of lower-limb Total Joint Arthroplasty (TJA) patients, to externally validate an adaptation of predictive tools and regression models published by three independent groups: Winemaker et al (2015)1, Oldmeadow et al (2003)2 and Gabriel et al (2018)3. Electronic medical records of a single, medium-sized public hospital were accessed to extract data required for the models and respective predictive tools, and model characteristics (included predictors, data coding, sample sizes) were modified according to the available data. ResultsThe study cohort comprised 200 patients (60% female) at a median 70yrs of age (IQR 62-75). Approximately 58% received total knee arthroplasty (TKA) and 42% underwent total hip arthroplasty (THA). The two prediction tools and three regression models all required modifications due to data items being unavailable in the electronic records. A modification of the RAPT tool applied to 176 eligible patients resulted in sensitivity of 85.71% (95%CI 71.46-94.57) and poor specificity 32.09% (24.29-40.70), with 68% of short-stay patients classified in the high risk group. Adaptation of the second tool to 85 eligible patients resulted in unreliable estimates of sensitivity due to limited data. The three adapted regression models performed similarly well with regard to discrimination when used to predict patients staying for 5 days or longer (concordance index: Winemaker et al:, 0.79, n=198; Oldmeadow et al: 0.79, n=176), or those staying 3 days or less (Gabriel et al: 0.70, n=199). Estimates of calibration suggested the models were relatively well calibrated (spiegelhalter Z -0.01-0.29, p>0.05), although calibration plots indicated some variation remained unaccounted for, particularly with patients considered at intermediate risk. ConclusionThe three resulting regression models performed adequately in terms of discrimination and calibration for identification of patients at risk of an extended stay. However, comparison with published models was hampered by systemic issues with data compatibility. Further evaluation of such models in a specific hospital setting should incorporate improvements in data collection, and establish key thresholds for use in targeting resources to patients in need of greater support.

BackgroundStructured Medication Reviews (SMRs) were introduced into primary care in England for patients living with multiple long-term conditions (MLTCs), polypharmacy, increased frailty, in care homes or at risk of medicines-related harm. SMRs aim to optimise the therapeutic potential of medication and reduce medicine-related harms through holistic reviews. AimTo explore the day-to-day work being undertaken with, and by, clinical pharmacists to implement, embed and integrate SMRs into practice, and consider how to optimise SMRs. Design and settingQualitative one-to-one interviews with clinical pharmacists undertaking SMRs and SMR service leaders/managers (SMR leads) in England between February 2023 and November 2024. MethodParticipants were recruited as part of a wider evaluation of the roll-out of SMRs in England. Interview topic guides and qualitative data analysis were informed by Normalization Process Theory (NPT). ResultsEighteen clinical pharmacists and five SMR leads participated. Participants reported often having to explain the purpose of SMRs and clinical pharmacists roles to patients, partly due to patients not being informed about SMRs. Participants valued SMRs and expressed that trust-building and tailored consultations were important for optimising medications. Integration varied due to high workload, inconsistent leadership support, inadequate administrative/pharmacist technician resource and lack of training. However, participants described SMRs as valuable for identifying and addressing unmet needs and supporting holistic, person-centred care across MLTC pathways. ConclusionThe findings demonstrate the need for improved information on SMRs for patients and primary care teams, adequate and appropriate resource allocation, and enhanced support for consultation skills training to optimise medicines use. How this fits in- SMRs were formally introduced to primary care in 2020 to address the challenges of managing polypharmacy in an ageing population with increasing patient complexity and MLTCs. - SMRs were introduced alongside the expansion of clinical pharmacist roles in General Practice as a comprehensive, person-centred review of all a patients medicines. - This qualitative evaluation examines the day-to-day work of implementing and embedding SMRs, highlighting challenges to implementation and integration. - Our findings reveal challenges to the sustainability of SMRs and identify opportunities for optimisation, including addressing pharmacists training needs and resource allocation for administrative and pharmacy technician support.

BackgroundCOVID-19 mandated a rapid and dramatic transformation of general practice. Total Triage (TT), where all consultations should be triaged first, and Remote-by-Default (RbD) consulting, where a clinician should consult remotely unless there is a "clinical exception", were advised. It is unclear how these new ways of working were implemented in practice, and how they impacted vulnerable patients. AimTo assess the impact of TT and RbD on vulnerable patients and identify mitigation strategies. Design and SettingA mixed methods service evaluation in Lewisham, London, an area of high deprivation. MethodThree parallel datasets were collected and analysed: Semi-structured interviews with stakeholders working with vulnerable groups and qualitative data from forums with black and ethnic minority patients, a survey of General Practitioners exploring implementation of TT and RbD, and a mystery shopper exercise reviewing access and messaging of ten practices. ResultsBarriers to access for vulnerable patients included challenges navigating the new model, difficulty engaging with remote consultations and digital exclusion. There was wide variation in messaging regarding changes to services and the practical application of TT and RbD. Potential solutions included clearer practice guidance and patient messaging, more consistent implementation, and identification and recording of patient access needs to enable better tailoring of care provision. ConclusionThis pilot study identified perceived and actual barriers to accessing general practice for vulnerable patients following the rapid introduction of TT and RbD consulting. It proposes immediate steps to mitigate some of these impacts and highlights the need for further research in this area. How This Fits InThe rapid and widespread adoption, recommended by NHS England, of total triage and remote-by-default consulting in general practice has yet to be evaluated. We provide a first look at how these changes are impacting those with historic difficulties in accessing primary care under the traditional GP model. We also provide some local recommendations that can be implemented easily at practice level and beyond, to mitigate the impact of these changes whilst making recommendations for further research to corroborate these findings widely.

Social prescribing has assumed increasing dominance in policy and practice internationally, including in the UK, where it has an increasing role in addressing social needs such as isolation, and social determinants of ill health. Although General Practitioners are perceived as key referral sources, social workers in one locality were found to play a significant role in referral. This suggests that the social work role in this context has been under recognised and under explored. This study sought to explore social workers' perceptions and experiences of social prescribing through an online survey conducted from January to June 2022. All UK social workers were eligible to participate, regardless of whether they had made referrals. A total of 105 responses were collected from all UK nations. Data was analysed using inductive thematic analysis. Four key themes were generated: contended and contested boundaries; complementary spaces; delineated spaces of simplicity and complexity; social work under threat. Participants recognised that social prescribing could provide valuable client support and could be a useful resource for social workers. However, they also expressed concerns about overlapping professional boundaries and the potential for social prescribing to encroach on social work, perceiving it as most appropriate for the delivery of support to those with 'low level' needs.

Objectiveto examine trends and variation in the use of Advice and Guidance (A&G) compared with direct referrals in primary care, and to assess potential disparities across population groups. DesignObservational study using routinely collected electronic health records SettingClinical Practice Research Datalink (CPRD) Aurum, 2015-2023. Main Outcome Measuresannual prevalence of A&G and direct referrals, stratified by age, gender, deprivation, locality, and ethnicity. Mapping of clinical codes was used to determine target specialities for A&G. The proportion of individuals recorded with A&G and a direct referral within {+/-}4 months was calculated. ResultsBetween 2015-2023, 671,894 patients (4%; 59% female) had A&G recorded and 9.7 million (59%; 46% female) had a direct referral. A&G use increased 19-fold from (0.10% to 1.97%), doubling between 2019 and 2020 during the COVID-19 pandemic. Direct referral rates fell from 23%-25% pre-pandemic to 18% in 2020 before recovering to 24% by 2023. Cardiology (21%), Dermatology (7%) and Ear, Nose and Throat (5%) were the most common specialties linked to A&G. Most patients receiving A&G (86%) also had a direct referral within {+/-}4 months. Inequities were evident: A&G use was higher among older, white, and less deprived patients, while minority ethnic and more deprived groups had slower recovery of direct referral rates post-pandemic. ConclusionA&G use has increased substantially since 2015, accelerated by the pandemic and maintained after, but has not displaced direct referrals. Instead, direct referral often precedes A&G, raising questions about efficiency and equity. The system appears to benefit older, white, and less deprived individuals while minority ethnic and more deprived groups remain disadvantaged. Policy should prioritise addressing these disparities and evaluate whether A&G reduces unnecessary referrals or delays access to specialist care. What is already known on this topic- Advice & Guidance (A&G) was introduced to support outpatient reform and manage NHS waiting lists. - Evidence on its usage patterns and equity across patient groups is limited. What this study adds- A&G use increased 19-fold between 2015 and 2023, particularly post-pandemic. - Disparities were identified with higher uptake in older, white and less deprived groups. - Direct referrals have recovered to pre-pandemic levels, suggesting A&G is not replacing traditional pathways.

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.

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.

BackgroundSelf-care is recognized as a cornerstone of modern health and care. The interface between health and care professionals (HCPs) and the public is pivotal in promoting self-care behaviours, yet barriers such as health literacy deficits, professional constraints, misconceptions and disparities in self-care confidence persist. ObjectiveThis study aimed to explore how self-care confidence, professional support and health literacy interact to influence self-care behaviours among UK adults, using a validated survey instrument to identify key disparities and enablers. MethodsA cross-sectional online survey was used to collect data from 3,255 UK adults including health and care professionals between January and September 2024. It explored demographic characteristics, self-care knowledge, health literacy, engagement with digital health resources and professional encouragement. Data were analysed using descriptive statistics and ordinal logistic regression. ResultsMost respondents (88.5%) reported confidence in maintaining a healthy lifestyle; only 62.0% felt confident managing common illnesses. Healthcare guidance accessibility was perceived as easy (77.4%) but not evaluating treatment options (51.4%) or mental health information accessibility (43.6%). HCPs overwhelmingly endorsed the importance of self-care (94.7%) but barriers included reluctance of patients/clients to engage or take responsibility (64.8%), understanding (59.0%), time constraints (42.7%) and health literacy challenges (45.8%). 68.6% found screening information accessible but 28.1% struggled with interpretation. Regression analyses revealed that older adults (65+) were significantly less confident in self-care with professional guidance (aOR=0.50, p=0.001), whereas males (aOR=1.41, p<0.001) and Black/Asian British individuals (aORs=2.31, 1.98; p<0.001) reported higher confidence levels. ConclusionThis study highlights the complex relationship between professional guidance, self-care confidence and health literacy. While most individuals value and engage in self-care, critical disparities persist, particularly in health literacy and access to digital resources. Targeted interventions and strengthening the public-healthcare professional dialogue and interface will be crucial in advancing self-care as a sustainable pillar of healthcare policy and practice.

PurposeA number of metrics and thresholds have been proposed to evaluate minimally meaningful change in the Oxford Hip and Oxford Knee scores (OHS and OKS). The study aim was to evaluate the impact of baseline scores on these metrics, and whether treatment success could be evaluated beyond these single metrics. Patients & MethodsThe data were collated from the National Health Service in England including the OHS, OKS and a global transition item (GTI). Minimally important change (MIC) scores were derived and categorised by the GTI, baseline and post-operative score categories. These metrics were also evaluated against standard error of measurement (SEM). ResultsA total of 387,524 records were extracted. Although the overall MIC were in-line with previous research, the results showed these measures varied by pre-operative scores. Few MIC estimates exceeded measurement error thresholds. Those that did were fell in the category of post-operative scores [&ge;] 30 for both instruments. ConclusionsThe MIC for both the OHS and OKS are potentially unreliable single metrics for evaluating meaningful change. A combination of baseline, post-intervention and change scores may provide more a robust measure for the evaluation of patient outcomes and healthcare services.

ObjectivesTo develop a simulation model to support orthopaedic elective capacity planning. MethodsAn open-source, generalisable discrete-event simulation was developed, including a web-based application. The model used anonymised patient records between 2016-2019 of elective orthopaedic procedures from an NHS Trust in England. In this paper, it is used to investigate scenarios including resourcing (beds and theatres) and productivity (lengths-of-stay, delayed discharges, theatre activity) to support planning for meeting new NHS targets aimed at reducing elective orthopaedic surgical backlogs in a proposed ring fenced orthopaedic surgical facility. The simulation is interactive and intended for use by health service planners and clinicians. ResultsA higher number of beds (65-70) than the proposed number (40 beds) will be required if lengths-of-stay and delayed discharge rates remain unchanged. Reducing lengths-of-stay in line with national benchmarks reduces bed utilisation to an estimated 60%, allowing for additional theatre activity such as weekend working. Further, reducing the proportion of patients with a delayed discharge by 75% reduces bed utilisation to below 40%, even with weekend working. A range of other scenarios can also be investigated directly by NHS planners using the interactive web app. ConclusionsThe simulation model is intended to support capacity planning of orthopaedic elective services by identifying a balance of capacity across theatres and beds and predicting the impact of productivity measures on capacity requirements. It is applicable beyond the study site and can be adapted for other specialties. Strengths and Limitations of this studyO_LIThe simulation model provides rapid quantitative estimates to support post-COVID elective services recovery toward medium-term elective targets. C_LIO_LIParameter combinations include changes to both resourcing and productivity. C_LIO_LIThe interactive web app enables intuitive parameter changes by users while underlying source code can be adapted or re-used for similar applications. C_LIO_LIPatient attributes such as complexity are not included in the model but are reflected in variables such as length-of-stay and delayed discharge rates. C_LIO_LITheatre schedules are simplified, incorporating the five key orthopaedic elective surgical procedures. C_LI

BackgroundThe outcome prioritisation tool (OPT) is a simple tool to ascertain the health outcome priorities of people with MLTC. Use of this tool in people aged under 65 years with MLTC has not previously been investigated. This study investigated the feasibility of using the OPT in people with MLTC aged 45 years or above, in a multi-ethnic primary-care setting, to describe the health outcome priorities of people with MLTC by age, clusters of long-term conditions and demographic factors, and to investigate any differences in prioritisation in light of the COVID-19 pandemic. MethodsThis was a multi-centre cross-sectional study using a questionnaire for online self-completion by people aged 45 years or above with MLTC in 19 primary care settings across the East Midlands, UK. Participants were asked to complete the OPT twice, first from their current perspective and second from their recollection of their priorities prior to COVID-19. ResultsThe questionnaire was completed by 2,454 people with MLTC. The majority of participants agreed or strongly agreed that the OPT was easy to complete, relevant to their healthcare and will be useful in communicating priorities to their doctor. Summary scores for the whole cohort of participants showed Keeping Alive and Maintaining Independence receiving the highest scores. Statistically significant differences in prioritisation by age, clusters of long-term conditions and employment status were observed, with respondents aged over 65 most likely to prioritise Maintaining independence, and respondents aged under 65 most likely to prioritise Keeping alive. There were no differences before or after COVID-19, or by ethnicity. ConclusionsThe OPT is feasible and acceptable for use to elicit the health outcome priorities of people with MLTC across both middle-aged and older age groups and in a UK setting. Individual factors could influence the priorities of people with MLTC and must be considered by clinicians during consultations. HIGHLIGHTSO_LISurvey data from 2,454 patients with MLTC showed that keeping alive and maintaining independence were the top first-choice priorities from the health outcome priorities tool (OPT). C_LIO_LIThe health outcomes priorities differed by socio-demographics and clusters of long-term conditions. C_LIO_LIThere were no differences in health outcomes priorities before and during COVID-19. C_LIO_LIOPT is easy and acceptable to implement in a health care setting in a broad patient group. C_LIO_LITranslation of the OPT into different languages is recommended to address any potential language barrier for people with MLTC completing the OPT C_LI

BackgroundPeople with severe and multiple disadvantage (SMD-combinations of homelessness, substance misuse, violence, abuse and poor mental health) have high health needs and poor access to primary care. AimTo explore perceptions and experiences of improving access to general practice for people with SMD in healthcare staff and people with lived experience. Design and SettingBridging Gaps is a collaboration between healthcare staff, researchers, women with lived experience of SMD and a charity that supports them in a UK city. We co-produced a project to improve access to general practice for marginalised patients, that was further developed with 3 inner city general practices. MethodWe observed six collaborative service improvement meetings at three general practices and conducted documentary analysis of minutes of a further three meetings. We interviewed nine practice staff and four participants with lived experience. Three participants with lived experience and one staff member who supports them participated in a focus group. Data was analysed inductively and deductively using thematic analysis. ResultsEnabling motivated general practice staff with time and funding opportunities, galvanised by lived experience involvement, resulted in sustained service changes. These included: care coordinators and patient lists to support access to patients in greater need and an information sharing tool. The process and outcomes improved connections within and between general practices, support organisations and marginalised patients. ConclusionThese co-produced strategies could be locally adapted and evaluated elsewhere. Investing in this different way of working may improve inclusion of marginalised groups, health equity and staff wellbeing. How this fits inThis study builds on previous work showing that continuity of care, being able to develop a trusting relationship and being proactive are of particular importance in providing care to highly marginalised patients(4, 5, 6, 7, 8). This work describes co-produced strategies including using care coordinators, patient lists and an information sharing tool to support access and continuity to patients in greater need, in addition to rich contextual information on how to shift ways of working to achieve this. In addition to a small team focused on marginalised patients, this study supports the literature highlighting the need for a trauma-informed approach throughout the whole practice team. These co-produced strategies could be adapted and piloted in other practices and areas. Investing in this focused way of working may improve inclusion of marginalised groups, health equity and staff wellbeing.