BJGP Open

ObjectivesTo use a proxy-measure of oral morphine equivalent dose (OMED) to determine trends in opioid burden in people with non-cancer pain and explore differences related to deprivation status. Design, setting and participantsRetrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from 78% of Welsh Primary Care General Practices, whose data is shared with the Secure Anonymised Information Linkage (SAIL) databank. Anonymised data for the period 2005 to 2015, for people aged 18 or over, without a recorded cancer diagnosis and who received at least one prescription for an opioid medicine was included. Primary and Secondary outcomesA proxy-measure of oral morphine equivalence dose (OMED) was used to describe trends in opioid burden over the study period. OMED burden was stratified by 8 drug groups and deprivation, based on the quintile measures of the Welsh Index of Multiple Deprivation 2011 (WIMD2011). ResultsIn the 11 years examined, 22 641 424 prescriptions for opioids were issued from 345 primary care general practices in Wales. Daily OMED per 1000 population increased by 94.7% (from 16 266 mg to 31 665 mg). Twenty-eight percent of opioid prescribing occurred in the most deprived quintile. More than 100 000 000mg more OMED was prescribed in the most deprived areas of Wales, compared to the least deprived. Codeine prescribing accounted for 35% of the OMED burden in Wales over the study period. ConclusionsWhilst opioid prescription numbers increased 44% between 2005 and 2015, the OMED burden nearly doubled, with a disproportionate OMED load in the most deprived communities in Wales. Using OMED provides an insightful representation of opioid burden, more so than prescription numbers alone. Socio-economic differences are likely to affect pain presentation, access to support services and increase the likelihood of receiving an opioid prescription. Strengths and limitations of this studyO_LIThis study forms part of the first large-scale examination of opioid prescribing in Wales and is the first to use oral morphine equivalent dose as an outcome measure. C_LIO_LIAccess to anonymously linked data allows more detailed examination of demographic influences on opioid prescribing. C_LIO_LIThe study used a proxy-measure for oral morphine equivalent dose due to unavailability of anonymously linked prescription dispensing data. C_LIO_LIDisproportionate levels of prescribing in particular populations have been reported in many countries; further research should seek to understand the reasons for the differences and develop means to address any inequality noted. C_LI

BackgroundPain is a major public health issue, and a common reason people seek medical care. Pharmacological treatments depend on the type of pain and carry different risks and benefits. The aim of this study was to examine trends in analgesic prescribing in Ireland and England between 2014 and 2022. MethodsMonthly data on medicines prescribed and dispensed in primary care were used. For Ireland, data on the means-tested General Medical Services (GMS) scheme were used, covering approximately 32% of the population. For England, data from the NHS Digital platform for all general practices were used. Outcomes were the volume of prescribed analgesic use, including rates of dispensings, costs, and standard doses (including oral morphine equivalents (OMEs) for opioids) per 1,000 population, summarised per year for each drug class/drug. ResultsIn Ireland, the rate of analgesia dispensings increased between 2014 and 2022 for most drugs. Opioid dispensings increased from 979 to 1,220 per 1,000 population, while paracetamol increased from 1,295 to 1,824. Systemic NSAIDs decreased from 781 to 734. In England, most analgesia dispensing rates decreased, with opioids decreasing from 721 to 585 per 1,000 population, paracetamol from 734 to 484, and systemic NSAIDs from 259 to 167. DiscussionSubstantially different dispensing patterns were found in Ireland and England, with higher increasing overall rates in Ireland and lower decreasing rates in England, potentially driven by the older age and lower socioeconomic status of GMS patients in Ireland. Further research to understand drivers for this higher volume of use is required.

BackgroundThe trends in sedative use have varied in recent years. Benzodiazepines and z-drugs are indicated for anxiety and sleep disorders, but should be limited to short term use. The aim of this study is to examine trends and patterns in sedative prescribing in Ireland between 2014 and 2022, as well as comparing trends between Ireland and England within the same period. MethodsMonthly data on medicines prescribed and dispensed in primary care on the means-tested General Medical Services (GMS) scheme in Ireland was used. Volumes of prescribed benzodiazepine and z-drug use and patterns of prescribing, including initiations, discontinuations, chronic use, and high-risk prescribing were summarised per year. Other sedating agents (sedating antihistamines, antidepressants, and antipsychotics) were also analysed. Volume of use outcomes were compared with NHS data from England for the same period. ResultsThe rate of benzodiazepine and z-drug dispensings per 1,000 GMS population decreased by 4%, from 1,531 in 2014 to 1,474 in 2022. T By comparison in England, there was a steeper decrease of 27% in the dispensing rate and the level of use was substantially lower, falling from 288 dispensings per 1,000 population in 2014 to 210 in 2022. In Ireland, dispensing rates were highest amongst women and older age groups. High-risk dispensings of benzodiazepines and z-drugs decreased over the study period DiscussionDespite decreases in benzodiazepine and z-drug dispensings, rates remain high in Ireland and may suggest a need for enhanced availability of non-pharmacological interventions, and improved education and deprescribing support for healthcare professionals. Statement of SignificanceThe use of benzodiazepines and z-drugs has decreased in many populations in recent years, while prescribing of other sedatives has increased. In Ireland, comparatively higher levels of prescribing have been previously identified. Describing and quantifying medication use is important to monitor medication safety at the population level, however this can be complex and therefore a range of indicators are needed to capture differences. The findings of this study suggest that benzodiazepine and z-drug dispensing is decreasing in Ireland, including high-risk dispensings and dispensings to older age groups. However, in comparison to England, dispensing rates remain high and suggest a need for enhanced availability of non-pharmacological services and interventions, as well as improved education and deprescribing support for healthcare professionals.

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.

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.

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 [≥] 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.

AimsDetermine factors affecting first return to work (RTW) status and time in patients treated with arthroscopic rotator cuff repair (aRCR) under state-based compensation schemes in New South Wales, Australia, compared to those outside such schemes. Material and MethodsPatients undergoing aRCR by one surgeon with minimum 1-year follow-up were grouped into those under (CP) or outside (non-CP) workers or vehicle accident compensation schemes, matched by age and gender. RTW status and time were assessed using chi-square analysis and multivariable linear regression. ResultsOf 1054 available patients, 90 CP patients were identified with 29 consented and matched to non-CP (N=29). A higher proportion of CP patients (17.2 vs 0%, P<0.001) never returned to work and a lower proportion resumed pre-injury duties at first RTW (3 vs 52%, P<0.01). Median time to first RTW did not differ between CP and non-CP groups (5.1 vs 4.4, P=0.86). Smoking (P=0.007) and post-injury activity level (P=0.004) were significantly associated with longer time to first RTW, whereas compensation status was not. ConclusionsCP patients undergoing aRCR in NSW are at risk of not returning to work. For those that do return, there is no significant difference compared to non-CP in time to first RTW. Particularly, patient and management factors associated with extended time to first RTW have been identified. Interventions aimed at modifiable factors such as smoking cessation and increasing preoperative activity may improve future outcomes.

BackgroundHealth literacy (HL) influences communication quality, treatment adherence, and equity in care. However, how general practitioners (GPs) recognize and respond to patients HL in everyday clinical reasoning remains insufficiently understood. ObjectiveTo investigate how Danish GPs incorporate patients health literacy into decisions about prescribing pain medication for chronic musculoskeletal pain, using insights from surveys, interviews, and a literature review. MethodsA mixed-methods design combined survey data from 39 Danish GPs, seven qualitative interviews, and a synthesis of 14 studies on HL in general practice. The literature was used to contextualize and contrast the empirical findings. Quantitative data were analyzed descriptively, while qualitative data underwent thematic analysis. All three datasets were integrated through mixed-methods comparison to assess convergence, divergence, and complementarity. ResultsAcross the integrated survey, interview, and literature findings, HL emerged as a largely implicit but consistent element of GP decision-making. In the Danish survey and interview data, some GPs explicitly reported considering HL in prescribing decisions, yet interviews showed that HL more often influenced clinical reasoning indirectly through intuition and conversation. GPs adapted communication, explanations, and treatment planning to their perceptions of patient understanding, but these adjustments were rarely guided by structured tools or frameworks. Conversation appeared as the main approach for assessing comprehension, echoing patterns observed in the literature. Many Danish GPs perceived most patients as competent and self-managing, a perception the literature cautions may mask hidden comprehension challenges. Finally, both local interviews and existing studies highlighted digital HL as an emerging theme, with GPs commonly managing patients online health information through conversational reframing rather than formal strategies. ConclusionsHL is tacitly integrated into GP reasoning but remains under-recognized as a professional skill. Making HL an explicit component of communication training, reflective practice, and prescribing guidelines could improve patient understanding, shared decision-making, and treatment equity.

AimsDefinitive and successful treatment of end stage ankle arthritis is either Total Ankle Replacement (TAR) or Ankle Fusion (AF). Both options place patients on an irreversible pathway that risks harm from further surgery. AF may predispose patients to subsequent hindfoot joint fusion and TAR is associated with high rates of complex revision surgery. The aim is to improve decision making by investigating the risks of further surgery, adjacent joint surgery and rare but serious complications of AF versus TAR. MethodsAn England population cohort study was performed using the Hospital Episode Statistics database, linked to ONS mortality data (19982023). The primary outcome was Kaplan Meier curve analysis of revision surgery free survival of TAR versus AF. Secondary outcome measures were the rates of adjacent joint/hindfoot fusion, any further reintervention to the ankle, perioperative mortality, 90 day complications, and serious adverse events. Results10,335 TAR and 30,704 AF were analysed. The AF revision rate was significantly lower than TAR at all time points including; 5 years (2% vs 6.1%, RR 0.12; 95% CI 0.10 to 0.16), 10 years (2.5% vs 10.2%, RR 0.12; 95% CI 0.08 to 0.18) and 20 years (3.1% vs 13.55%, RR 0.12; 95% CI 0.01 to 0.23). There was no significant difference in 25 year risk of adjacent joint fusion following AF (8.64%, 95% CI 7.79% to 9.58%) versus TAR (6.82%; 95% CI 5.36% to 8.66%). TAR was associated with higher risks of intra operative fracture (0.42% vs 0.10%, RR = 4.35) and reintervention for wound infection (0.26% vs 0.15%, RR 1.74) but fewer pulmonary emboli (0.23% vs 0.58%, RR = 0.40). ConclusionBoth TAR and AF are safe definitive treatments of ankle arthritis with low perioperative risk. TAR is associated with a significantly higher rate of further revision surgery than AF. AF does not predispose patients to hindfoot fusion surgery.

ObjectivesThis is the first national study observing the impact of the COVID-19 pandemic on orthopaedic trauma with respect to referrals, operative caseload and mortality during the first six weeks (namely the "golden peak weeks") following the introduction of the national social distancing and lockdown measures from mid-March 2020. DesignA longitudinal, national, multi-centre, retrospective, observational, cohort study was conducted for the first six weeks from March 17, 2020 from start of the national social distancing and then lockdown compared to the same period in 2019 as a comparative baseline. SettingHospitals from seven major urban cities were recruited around the UK, including London, representing a comprehensive national picture of the impact of COVID-19 pandemic and its lockdown at its peak. ParticipantsA total of 4840 clinical encounters were initially recorded. Exclusion criterion consisted of spinal pathology only. Post-exclusion, 4668 clinical encounters were recorded and analysed within the two timeframes. Main outcome measuresPrimary outcomes included the number of acute trauma referrals and those undergoing operative intervention, patient demographics, mortality rates, and the proportion of patients contracting COVID-19. Secondary outcomes consisted of the mechanism of injury, type of operative intervention and proportion of aerosolising-generating anaesthesia utilised. Demographics for each patient was recorded along with underlying medical co-morbidities. Sub-group analysis compared mortalities between both cohorts. Statistical analyses included mean ({+/-}SD), risk and odds ratios, as well as Fishers exact test to calculate the statistical significance (p[&le;]0.05). ResultsDuring the COVID-19 period there was a 34% reduction in acute orthopaedic trauma referrals compared to 2019 (1792 down to 1183 referrals), and 29.5% less surgical interventions (993 down to 700 operations). The mortality rate significantly (both statistically and clinically) more than doubled for both risk and odds ratios during the COVID period in all referrals (1.3% vs 3.8%, p = 0.0005) and in those undergoing operative intervention (2.2% vs 4.9%, p = 0.004). Moreover, mortality due to COVID-related complications (versus non-COVID causes) had greater odds by a factor of at least 20 times. The odds ratios of road traffic accidents, sporting injuries, infection, and lower limb injuries were significantly less (by a third to a half) during the COVID period; albeit, the odds of sustaining neck of femur fractures and having falls < 1.5m increased by more than 50%. For the operative cohorts, there was a greater odds of aerosolising-generating anaesthesia (including those with superimposed regional blocks) by three-quarters as well as doubling of the odds of a Consultant acting as the primary surgeon. Nevertheless, the odds of open reduction and internal fixation reduced by a quarter whereas removal of metalwork or foreign bodies reduced by three-quarters. Six-week Kaplan-Meier survival probability analysis confirmed those patients with neck of femur fracture and pre-existing cardiovascular and cerebrovascular disease were most at risk of mortality during the COVID-19 era. ConclusionAlthough there was a reduction of acute trauma referrals and those undergoing operative intervention, the mortality rate still more than doubled in odds during the peak of the pandemic compared to the same time interval one year ago. Elderly patients with neck of femur fractures and existing cardiovascular and cerebrovascular comorbidities were at the highest risk stratification for mortality. This was the first national study to assess impact of COVID-19 pandemic on acute Orthopaedic trauma and it will aid clinicians in counselling trauma patients of the increased risk of mortality during the era of COVID-19 as well as acting as a risk-prediction tool influencing policymaking as the pandemic continues with potential subsequent waves. Further studies after the lifting of the lockdown are also required to observe for return of standard practice.

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.

BackgroundThe COVID-19 pandemic has had a significant impact on primary care service delivery. With general practice delivering record numbers of appointments and rising concerns around access, funding and staffing in the UK National Health Service, we assessed contemporary trends in consultation rate and mode (face-to-face versus remote). MethodsWe did a retrospective analysis of 9,429,919 consultations by GP, nurse or other health care professional between March 2018 and February 2022 for patients registered at 397 English general practices. We used routine electronic health records from Clinical Practice Research Datalink Aurum with linkage to national datasets. Negative binomial models were used to predict consultation rates and modes (remote versus face-to-face) by age, sex, and socio-economic deprivation. FindingsOverall consultation rates increased by 15% from 4.92 in 2018-19 to 5.66 in 2021-22 with some fluctuation during the start of the pandemic. Consultation rates increased with deprivation. The breakdown into face-to-face and remote consultations shows that the pandemic precipitated a rapid increase in remote consultations across all groups but varies by age. Socioeconomic differences in consultation rate, adjusted for sex and age, halved during the pandemic (from 0.36 to 0.18 more consultations in the most deprived). The most deprived saw a relatively larger increase in remote and decrease in face-to-face consultations rates. InterpretationSubstantial increases in consultation rates imply increased pressure on general practice. The narrowing of consultation rates between deprivation quintiles is cause for concern, given ample evidence that health needs are greater in more deprived areas. FundingNo external funding. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSPressure on general practice has increased over recent years and there is consensus that the COVID-19 pandemic added to this. There is also consensus that the way general practice is delivering care has changed with increased use of remote consultation but there no estimates of the full extent of this and uptake by different groups. A seminal paper - Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007-14 - found an increase in consultation rates over the study period and in increased reliance on telephone contacts even before the pandemic. Added value of this studyThis study reports recent data for general practice consultation rates overall and by delivery mode. Our findings show that overall consultation rates were higher in 2021-22 than prior to the pandemic and that there has been a shift from face-to-face to remote consultations. However, the increase in overall consultations rates varies between index of multiple deprivation quintiles when adjusting for age and sex. These findings are based on close to 10 million consultations and 2 million person-years of observation from a validated data base of routinely collected electronic clinical records (the Clinical Practice Research Datalink Aurum). Implications of all the available evidenceOur analysis shows that general practice is busier than ever. We provide details on the use of remote versus face-to-face consultations by different patient groups over time. The narrowing of the difference between consultation rates of deprivation quintiles implies increasing health inequality in the population as existing differences in health needs are therefore not fully reflected in the consultation rates. The relatively larger increase in remote consultation rates and drop in face-to-face consultations for the most deprived provides detail on what type of consultations different patient groups receive but also raises additional questions.

BackgroundSocial prescribing (SP) is growing rapidly in England and across the world. However, whom it is reaching and how effectively it is being implemented remains unclear. This study aimed to assess longitudinal trends in SP in Englands primary care system, including growth trajectories and target alignment, sociodemographic profiles of referred patients, and predictors of service refusal over time. MethodsThis study analysed primary care records from 1.2 million patients from 1,736 practices in the Clinical Practice Research Datalink in England. We estimated SP trends between 2019 and 2023 using growth curve modelling on SP numbers at practice level. Descriptive analyses were used to show changes in sociodemographic profiles of SP patients over time. To assess sociodemographic disparities in service refusal (defined as having a medical code of social prescribing declined), we used multilevel logistic regression models stratified by year, accounting for nested data structure where patients were nested within practices. FindingsAs of the end of 2023, an estimated 9.4m GP consultations in England have involved SP codes, and 5.5m consultations have specifically led to SP referrals. In 2023, females constituted 60% of SP patients and ethnic minority groups represented 23%. Representation from patients living in more deprived areas increased from 23% to 42% between 2017-2023. Service refusal declined from 22% to 12% between 2019-2023. Age, sex and ethnicity were associated with service refusal across multiple years. In 2023, notably, all age groups had higher odds of refusal compared to the youngest age group. Females had 21% lower odds of refusal than males (95% CI=0.77-0.82), and patients from white ethnic backgrounds had 32% higher odds of refusal than ethnic minority patients (95% CI=1.26-1.39). InterpretationSP has expanded rapidly in England, far exceeding initial targets of 900,000 patients by 2023/24 and suggesting broad service acceptability. Progress is being made in reaching certain target groups such as more deprived communities. However, there are still disparities in accessibility and uptake, calling for targeted strategies to address underlying inequalities. FundingMQ Transforming Mental Health, Rosetrees-Stoneygate Trust Fellowship, National Academy for Social Prescribing Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe systematically searched PubMed, PsycINFO, Cochrane Library, Web of Science, and OpenGrey for studies (including grey literature) published in English between January 1980 and March 2025, using search terms such as social prescribing, non-medical referral/intervention, non-clinical referral/intervention, community referral, referral scheme. Prior evidence on rates and patterns of referrals was limited to small-scale evaluations, cross-sectional data, or regional analyses, with a lack of nationally representative longitudinal studies examining implementation trends or equity. Systematic reviews highlighted gaps in understanding disparities in service access and uptake. While the National Health Service (NHS) Long Term Plan (2019) set ambitious targets for SP, no studies had quantified progress toward these goals since the national rollout. Added value of this studyUsing primary care medical records from the Clinical Practice Research Datalink (CPRD), this study provides the first longitudinal, national analysis of SP implementation across 1.2 million patients in England. We demonstrate that SP referrals exceeded NHS targets by 27-51% in 2023, with at least 1.1-1.4 million patients receiving referrals. The analysis reveals significant progress in reaching deprived populations (representation increased from 23% to 42% between 2017-2023) but identifies persistent disparities in service uptake across age, sex, and deprivation groups. Implications of all the available evidenceThe rapid expansion of SP reflects its growing integration into primary care. However, persistent sociodemographic disparities highlight the need for targeted interventions to ensure equitable service access and uptake. This study provides policymakers with evidence to standardise referral protocols and allocate resources to underserved areas. Future research should rigorously track the implementation of SP, evaluate its long-term health outcomes and cost-effectiveness to fulfil its potentials as a key component of universal personalised care.

BackgroundDay case total shoulder arthroplasty (TSA) is a novel approach, not widely practiced in Europe. We conducted a retrospective cohort study of patients comparing elective day case and inpatient TSAs in our UK centre. AimTo evaluate the efficacy and cost-effectiveness of day case total shoulder arthroplasty (TSA) compared to standard inpatient total shoulder arthroplasty. MethodsAll patients undergoing TSA between January 2017 and July 2018 were included. Outcome measures were: change in abduction and extension 3 months postoperatively; 30 day postoperative adverse events and re-admissions in day case and inpatient groups. We also conducted an economic evaluation of outpatient arthroplasty. Multivariate linear and logistic regression were used to adjust for demographic and operative covariates. Results59 patients were included, 18 day cases and 41 inpatients. There were no adverse events or re-admissions at 30 days postoperatively in either group. There were no significant differences in adjusted flexion (mean difference 16.4{degrees}; 95% CI -17.6{degrees} to 50.5{degrees}, p=0.337) or abduction (mean difference 13.2{degrees} 95% CI; -18.4{degrees} to 44.9{degrees}, p=0.405) postoperatively between groups. Median savings with outpatient arthroplasty were GBP 529 (IQR 247.33 to 789, p<0.0001). ConclusionDay case TSA is a safe, effective procedure, with significant cost benefit. Wider use may be warranted in the UK and beyond, with potential for significant cost savings and improved efficiency. Core tipIn this article we show that day case total shoulder arthroplasty is a feasible, safe and effective alternative to inpatient admission for the same procedure, with an associated average cost saving of GBP 529.

BackgroundChronic pain is common among older adults with frailty and its management often remains suboptimal, despite evidence for the benefits of biopsychosocial treatment approaches being found for other populations. The Pain in Older People with Frailty Study (POPPY) was a four-phase study that aimed to develop a service model for pain management for this population to enable them to better manage their pain and reduce its impact on their lives. The aim of Phase 3 of the POPPY study was to understand the views of those delivering and commissioning services relating to older adults engagement in services and how pain services could be maximised to meet their needs. MethodsWe used in-depth semi-structured interviews with healthcare professionals (HCPs) and commissioners to explore: 1) perceptions of opportunities and barriers to including and managing older adults in pain services within different contexts, and 2) how to maximise support for this population in community, primary care, secondary care, and tertiary pain services. A thematic approach was used to analyse the data. FindingsWe recruited participants from 9 pain and 2 generic community services in the north, southeast and west of England. Services were in community, primary care, secondary care, and tertiary settings. We interviewed 42 HCPs including clinicians, psychologists, allied health professionals, nurses, social prescribers, service managers, and health/wellbeing coaches. We also interviewed 2 service commissioners. Most participants recognised that older adults living with frailty and pain often shared characteristics relating to their physical health, life experience and social circumstances which shaped their engagement in pain services. Generally, participants perceived there to be reduced engagement in pain services among older adults with frailty. Factors that were likely to improve the management of pain in the older population both within pain and non-pain services were also identified. ConclusionsFor pain services to meet the needs of older adults with frailty, it is essential for them to be responsive to the specific needs of this population, adapting both the content and delivery of interventions accordingly. Trial registrationresearch registry7169/ IRAS project ID: 310174

BackgroundOxycodone is widely prescribed for managing acute pain in emergency departments (ED), but the appropriateness of this prescription is not fully established. Although concerns about opioid misuse and dependence drive efforts to reduce inappropriate prescribing, there is increasing recognition of the importance of adequate pain management. Therefore, it is essential to develop appropriate prescribing criteria that balance the risks and benefits of opioids, ensuring their benefits are maximised while minimising potential harm. ObjectiveFollowing the recommended format for a research protocol paper, this protocol describes the process and methods used to develop evidence-based criteria for oxycodone prescribing in the ED, informed by scientific evidence and expert clinical judgment, using the RAND/UCLA Appropriateness Method. MethodThe process will be carried out in sequential stages. First, scope and key terms will be defined, and then a targeted literature review will be conducted to synthesise available evidence. Subsequently, based on this synthesis and the investigator teams clinical insights, clinical scenarios will be developed in collaboration with field experts. A multidisciplinary panel comprising specialists in emergency medicine, emergency nurses, and pharmacists will evaluate these scenarios in two rounds. Each scenario will be rated on a 1-9 scale, where 1 indicates that harm outweighs benefit and 9 indicates that benefit outweighs harm. The median rating score will fall between 1 and 9, where 1-3 without disagreement is inappropriate, 4-6 without disagreement is uncertain, and 7-9 without disagreement is appropriate. Disagreement is defined as at least three experts scoring in both extremes. Final scenario ratings will be presented according to their assessed appropriateness and used to inform appropriateness criteria for prescribing oxycodone in the adult ED. ConclussionThe RAND/UCLA Appropriateness Method offers a systematic and evidence-informed framework for developing prescribing criteria to support the appropriate use of oxycodone in adult ED.

IntroductionDigital transformation and integration of eHealth solutions into chronic pain management faces significant challenges that have not yet been met. To realize the potential of eHealth solutions there is a need to understand the challenges, needs and care processes of eHealth into specific contexts and specific purposes. The objective of this study was to explore challenges, barriers, support needs, and visions experienced by patients and general practitioners (GPs) in the context of an eHealth solution designed for chronic pain management in general practice. MethodsThe study used action-research as a methodological framework. We conducted two future workshops involving eight patients living with chronic pain and seven GPs with clinical experience in managing chronic pain. Through case vignettes and inspiration cards, these workshops stimulated discussions and shared knowledge construction. Data were analysed using reflexive thematic analysis, separated by the groups, and were synthesized via a matrix analysis. ResultsThe analysis revealed five content summary themes: Theme 1--patients experience of challenges in life with pain; Theme 2--challenges in treating patients with chronic pain; Theme 3--patients suggestions for the structure of the eHealth solution; Theme 4--GP suggestions for the structure of the eHealth solution; and Theme 5--differences and similarities: Visions for an eHealth solution. The analysis generated several touchpoints and tension within the patient-physician encounter. ConclusionIn conclusion, these themes provide distinct narratives, offering valuable insights into the design objectives. Our study represents a significant advancement in developing personalized and innovative eHealth solutions for general practice, addressing key clinical challenges. PerspectiveRealizing the potential of eHealth solutions, these findings highlight both contrasting and shared viewpoints on design objectives, providing crucial insight into end-user perspectives for effective pain management. Additionally, the study underscores the importance of supported self-management and clinical communication in understanding each patients overall presentation within the healthcare system.

AimsTo describe activity and outcomes after streaming low urgency attenders to general practice services at door of Accident and Emergency departments (GDAE), including possible benefits to co-located emergency departments. MethodsAs a service evaluation, we describe GDAE users, their reasons for presentation, wait times, outcomes and co-located emergency department performance metrics at two hospitals in eastern England. FindingsEach GDAE saw about 928 patients per month. Wait times for usual A&E care relatively shortened at only one site. Reattendances were common (about 10% of attenders), 75% of GDAE attenders were seen within 1 hour of arrival, 7% of patients initially allocated to GDAE were referred back to A&E for further investigations, 59% of GDAE patients were treated and discharged with no further treatment or referral required. Pain, injury, infection or feeling generally unwell each comprised > 10% of primary reasons for attendance. Referrals to specialist health services were outcome for 4% and 16% at respective sites. ConclusionsAbout 26,000 A&E attendances appear to have been prevented. Patients were seen quickly at both GDAE sites, while there were more specialist referrals or shorter wait times for usual A&E services at only one site. Process evaluation could illuminate reasons for these differences.

TitleFactors influencing English general practitioners referrals to specialist sleep services: a qualitative study using the COM-B model ObjectivesThis study explored the factors influencing access to sleep services for individuals with symptoms of OSA and narcolepsy, from the perspective of general practitioners (GP). MethodsA qualitative interview study was conducted with GPs within three areas of England: South London, East Midlands or South West England to explore their views on factors influencing referrals to specialist sleep services. The semi-structured interviews were conducted between November 2024 and April 2025 using an interview guide informed by published research and the COM-B model of behaviour change; this model proposed that Capability (C), Opportunity (O), and Motivation (M) are needed for behaviour (B) change to occur. Data were analysed using exploratory thematic analysis informed by the COM-B model using an iterative approach. ResultsWe conducted 31 interviews, mostly online, with one conducted face-to-face. Our data suggest that the most important factors shaping referral to sleep services are limited capacity of NHS sleep services, limited referral pathways for narcolepsy, inflexible referral pathways for OSA, and limited knowledge of narcolepsy. ConclusionsThis qualitative study with GPs in England highlights that, although sleep disorders are a common concern, the current healthcare system provides limited support for GPs in managing these conditions. Fundamental sleep medicine service reforms are needed to improve referral pathways. These reforms should be guided by data-driven research that assesses current services in relation to population health needs and evaluates the potential health and economic benefits of expanding service capacity.

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 [&ge;]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 [&ge;]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.