British Journal of General Practice

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.

ObjectiveTo describe the impact of the COVID-19 pandemic on safe prescribing, using the PINCER prescribing indicators; to implement complex prescribing indicators at national scale using GP data. DesignPopulation based cohort study, with the approval of NHS England using the OpenSAFELY platform. SettingElectronic health record data from 56.8 million NHS patients general practice records. ParticipantsAll NHS patients registered at a GP practice using TPP or EMIS computer systems and recorded as at risk of at least one potentially hazardous PINCER indicator between September 2019 and September 2021. Main outcome measureMonthly trends and between-practice variation for compliance with 13 PINCER measures between September 2019 and September 2021. ResultsThe indicators were successfully implemented across GP data in OpenSAFELY. Hazardous prescribing remained largely unchanged during the COVID-19 pandemic, with only small reductions in achievement of the PINCER indicators. There were transient delays in blood test monitoring for some medications, particularly ACE inhibitors. All indicators exhibited substantial recovery by September 2021. We identified 1,813,058 patients at risk of at least one hazardous prescribing event. ConclusionGood performance was maintained during the COVID-19 pandemic across a diverse range of widely evaluated measures of safe prescribing. Summary box O_TEXTBOXWHAT IS ALREADY KNOWN ON THIS TOPICO_LIPrimary care services were substantially disrupted by the COVID-19 pandemic. C_LIO_LIDisruption to safe prescribing during the pandemic has not previously been evaluated. C_LIO_LIPINCER is a nationally adopted programme of activities that aims to identify and correct hazardous prescribing in GP practices, by conducting manual audit on subgroups of practices. C_LI WHAT THIS STUDY ADDSO_LIFor the first time, we were able to successfully generate data on PINCER indicators for almost the whole population of England, in a single analysis. C_LIO_LIOur study is the most comprehensive assessment of medication safety during the COVID-19 pandemic in England, covering 95% of the population using well-validated measures. C_LIO_LIGood performance was maintained across many PINCER indicators throughout the pandemic. C_LIO_LIDelays in delivering some medication-related blood test monitoring were evident though considerable recovery was made by the end of the study period. C_LI C_TEXTBOX

BackgroundPharmacy First, a national community pharmacy service, launched in January 2024 to improve access to primary care for patients with minor conditions facing backlogs caused by the COVID-19 pandemic. Pharmacies are required to share details about their consultations with general practices. We aimed to describe how and what clinical activity was recorded in general practice during the first year of the service. MethodsWith the approval of NHS England, we conducted a retrospective cohort study using OpenSAFELY-TPP including Pharmacy First consultations between 31 January 2024 and 30 January 2025. We described patient demographics, consultation trends, and the clinical conditions and medications coded with Pharmacy First consultations. ResultsA total of 402,165 Pharmacy First consultations were recorded for 340,710 patients from a general population of 26,142,380 registered patients in OpenSAFELY-TPP. Acute pharyngitis (28.9%) and uncomplicated urinary tract infection (28%) were the most frequently recorded conditions. By January 2025, 36.3% of recorded Pharmacy First consultations had a clinical condition, medication, or both. Females, younger adults and those living in more deprived areas were observed more often in Pharmacy First records compared to the general population. ConclusionIncreasing recording of the Pharmacy First community pharmacy service was observed in general practice records during its first year, particularly among younger and more deprived populations. However, variation in structured recording of consultation details may limit evaluation.

ObjectivesThe present study aimed to evaluate the impact of structured medication reviews (SMRs), by examining the proportion of eligible patients who received a review in the first two years of the programme, and whether SMRs were associated with changes in prescribing. DesignRetrospective observational cohort study. SettingPatients registered to primary care practices in England contributing data to the Oxford Clinical Informatics Digital Hub (ORCHID) were included between 1st April 2020 and 30th September 2022. ParticipantsDe-identified data were extracted from the electronic health records of individuals registered to ORCHID practices aged [≥]65 years, prescribed one or more medications and fulfilling the specific eligibility criteria for a SMR. Main outcome measuresThe primary outcome was the proportion of patients who received a review. Further outcomes included the proportion of potentially inappropriate drug combinations corrected following an SMR. The association between SMRs and prescription changes and primary care contacts was examined by matching individuals who received an SMR to individuals who did not receive an SMR, according to age, sex and primary care practice using cumulative density sampling. Analyses were undertaken using adjusted logistic regression. ResultsFrom a total of 635,698 eligible patients, 82,285 patients (12.94%, 95% confidence interval [CI] 12.86% to 13.02%) received at least one SMR during the study observation period. In those prescribed potentially inappropriate drug combinations prior to an SMR, between 12.5% and 40.0% were corrected up to three months later. In matched analyses, SMRs were associated with a significant increase new prescriptions of ACE inhibitors (adjusted odds ratio [aOR] 1.56, 95%CI 1.35-1.81), statins (aOR 1.78, 95%CI 1.57-2.02), inhaled corticosteroids (aOR 1.19 95%CI 1.05-1.36), opioids (aOR 1.31 95%CI 1.20-1.42), and antidepressants (aOR 1.45 95%CI 1.28-1.63). In those previously prescribed treatment, individuals receiving an SMR were significantly more likely stop ACE inhibitors (aOR 1.37, 95%CI 1.18-1.58), statins (aOR 1.35, 95%CI 1.17-1.56) and antidepressants (antidepressants aOR 1.37 95%CI 1.21-1.56). SMRs were associated with a significant increase in primary care contacts of 0.14 (95% CI 0.13 to 0.16; equivalent to 14 extra patient contacts for every 100 individuals receiving an SMR). ConclusionsSMRs were associated with starting new medications and stopping existing prescriptions compared to usual care. It was unclear if such activity was appropriate or represented improved patient care. Further work is needed to understand if these changes in prescribing improved patient outcomes. What is already known on this topicO_LIInappropriate polypharmacy can expose the most vulnerable patients to decreased quality of life and adverse drug events. C_LIO_LIOutside of trials, studies of pharmacist-led medication reviews undertaken in routine clinical practice have shown little impact on prescribing and patient-centred care. C_LIO_LIStructured medication reviews are a National Institute for Health and Care Excellence (NICE) approved clinical intervention to address complex or problematic polypharmacy and were introduced widely in the UK NHS in 2020. C_LI What this study addsO_LIWe found that one in eight eligible patients received a structured medication review during the first two years of the programmes rollout in England. C_LIO_LIStructured medication reviews were associated with an increased likelihood of starting medication in those not previously prescribed treatment, and an increased likelihood of stopping medications in those with existing prescriptions. C_LIO_LIThis analysis was limited by the data available within primary care electronic health records and so it is unclear if the observed changes in prescribing resulted in improvements in patient outcomes C_LI

BackgroundThe Additional Roles Reimbursement Scheme (ARRS) was introduced by NHS England in 2020 alongside Primary Care Networks (PCNs) with aims of increasing the workforce and improving patient outcomes. AimDescribe the uptake of direct-patient care (DPC)-ARRS roles and its impact on patients experiences. Design and SettingEcological study using 2020-2023 PCN and Practice workforce data, registered patient characteristics, the General Practice Patient Survey, and the Quality and Outcomes Framework (QOF). MethodsDescriptive statistics with associations examined using quantile and linear regression. ResultsBy March 2023, 17,588 FTE DPC-ARRS roles were commissioned by 1,223 PCNs. PCNs with fewer constituent practices had more DPC-ARRS roles per population (p<0.001) as did PCNs with more FTE GPs per population (p=0.005). DPC-ARRS commissioning did not vary with age, proportion female or deprivation of practice populations. DPC-ARRS roles were associated with small increases in patient satisfaction (0.8 percentage points increase in patients satisfied per one DPC-ARRS FTE) and perceptions of access (0.7 percentage points increase in patients reporting good experience of making an appointment per one DPC-ARRS FTE), but not with overall QOF achievement. ConclusionsThe commissioning of DPC-ARRS roles was associated with small increases in patient satisfaction and perceptions of access, but not with QOF achievement. DPC-ARRS roles were employed in areas with more GPs rather than compensating for a shortage of doctors. Single practice PCNs commissioned more roles per registered population, which may be advantageous to single practice PCNs. Further evaluation of the scheme is warranted. How this fits inO_LIPrimary Care Networks (PCNs) commissioning of non-GP direct-patient care (DPC) roles via the Additional Roles Reimbursement Scheme (ARRS) has expanded rapidly, with an allocated budget of {pound}110m in 2019/2020 employing 279 full time equivalent (FTE) DPC-ARRS staff in March 2020, to {pound}1,027m in 2022/2023, employing 17,588 FTE DPC-ARRS staff in March 2023. C_LIO_LIPrevious research, using NHS England data prior to 2020, had reported associations between increased Healthcare Associate Professionals employment and reductions in patient satisfaction and perceptions of access, with no impact on Quality and Outcomes Framework (QOF) achievement, but it was not known if these trends remained after the implementation of ARRS. C_LIO_LIThis study found a small increase in both overall patient satisfaction and perceptions of access, which equates to approximately 240-400 patients satisfied with their care and 210-350 patients able to make appointments for each FTE in ARRS roles employed in a typical PCN (30,000-50,000 patients), but no association with overall QOF achievement. C_LIO_LIFurther evaluation is required to identify if the observed associations can be attributed to the ARRS roll-out and if this represents value for money. C_LI

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.

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.

BackgroundThe migration status of the 9.8 million migrants living in England is not systematically recorded in primary care electronic health records (EHRs). Codelist approaches enable us to create cohorts of individuals who have had a predefined, optional migration-related code (e.g. "refugee") added to their EHR. AimsWe aimed to explore the use of migration-related SNOMED CT codes to inform future research using primary care data. Design and SettingWe used our Open Code Counts tool and R package to explore data published by NHS England on SNOMED CT code usage in English primary care. MethodWe created migration-related codelists and described their use from 1st August 2011 to 31st July 2024. We compared code usage to trends in migration-related statistics from the Home Office and the 2021 Census. ResultsThere were 29.1 million uses of 1,114 migration-related codes from 2011 to 2024. Migration-related coding increased over time, exceeding the increase observed for coding overall, with a sharp increase from 2020, particularly for country-of-birth and language. Language coding represented 71% of code usage and where country of birth was recorded, there was mixed agreement with the census estimates. Coding of immigration legal statuses was low and overwhelmingly about asylum or refugee status. ConclusionRapid assessment of migration-related coding using Open Code Counts highlights that a non-English first language is the most strongly represented characteristic in migrant cohorts in English primary care EHRs, which should be considered when interpreting future research findings. How this fits inThis study offers population-wide insights into migration-related SNOMED CT coding in primary care in England from 2011 to 2024 using our new open-source tool, Open Code Counts. Here, we show that a first language that is not English is the most commonly recorded aspect of migration, which must be considered when interpreting results from studies that use this methodology for researching migrants health in primary care EHRs. We also show that migration-related coding has increased, particularly after the start of the pandemic and for country-of-birth and language codes. The increased use of these code types offers the opportunity for GP practices to better identify patients requiring language support and potential screening and service needs based on their country of birth. Summary sentenceLanguage is the most commonly coded aspect of migration in primary care, which must be considered when interpreting primary care data studies.

BackgroundPopulation ageing has led to an increase in multimorbidity and polypharmacy. Some medications may need to be stopped, but patient attitudes towards deprescribing are poorly understood. This study explores attitudes towards (de)prescribing in patients with multimorbidity in the UK primary care. MethodsPatients with multimorbidity were invited to complete the Revised Patients Attitudes Towards Deprescribing (rPATD) Questionnaire using an Evergreen Lifes Personal Health Record App (Manchester, UK). The responses were linked to electronic health records. Anonymised data were analysed in a trusted research environment (University of Liverpool) for group comparisons and using multivariable logistic regression to identify factors associated with satisfaction with current medications. ResultsA total 1,019 patients participated in the study (n=365 aged <65, 30% males; n=654 [&ge;]65, 57% males). Most patients were satisfied with their current medications (74% aged <65, 70% aged [&ge;]65) but were willing to stop one or more of their regular medicines if their doctor said it was possible (82%, 68% accordingly). Polypharmacy, use of antihypertensive drugs, and antidepressants were associated with patient-reported burden in taking medicines. Frailty did not influence patient deprescribing attitudes. Patients who were satisfied with current medications had fewer medications. Independent predictors of satisfaction with current medications were higher total involvement and appropriateness scores, and lower total burden score. ConclusionsMost patients with multimorbidity would consider stopping some of their medications, even when they are generally satisfied with the treatments they received. Frailty status does not imply willingness to stop medications. Clinicians should discuss medication deprescribing for shared decision.

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.

The COVID-19 pandemic had a substantial impact on healthcare delivery, particularly in general practice. This study aimed to evaluate how dispensing of medications in primary care in Ireland changed following the COVID-19 pandemics onset compared to expected trends. This interrupted time series study used data on medications prescribed in general practice 2016-2022 to patient eligible for state health cover, approximately one third of the population. Dispensing volumes for all therapeutic subgroups (ATC2 codes) and commonly dispensed medications were summarised. Pre-pandemic data was used to forecast expected trends (with 99% prediction intervals) using the Holt-Winters method, and these were compared to observed dispensing from March 2020 onwards. Most (31/77) therapeutic subgroups had dispensing significantly different from forecast in March 2020. Drugs for obstructive airway disease had the largest difference, with dispensing 26.2% (99%CI 19.5%-33.6%) higher than forecasted. Only two subgroups were significantly lower than forecasted, other gynaecologicals (17.7% lower, 99%CI 6.3%-26.6%) and dressings (11.6%, 99%CI 9.4%-41.6%). Dispensing of amoxicillin products and oral prednisolone were lower than forecasted in the months following the pandemics onset, particularly during winter 2020/2021. There was a spike in dispensing for many long-term medications in March 2020, while pandemic restrictions likely contributed to reductions for other medications.

BACKGROUNDIt is assumed that there is universal provision of the maternal postnatal 6-8 week check (6WC) in primary care following the introduction of additional funding provided through the General Medical Services contract in 2020/21. Prior to the pandemic, it is estimated that 20-40% of women in England did not have a postpartum maternal check recorded in primary care. Concerned that changes in local appointment access were contributing to an inequitable provision of postnatal care, we explored a model of access that improved the delivery of maternal postnatal care in general practice AIMTo design a primary care model of access to improve the uptake of the maternal postnatal check that prioritised equitable access to care. DESIGN AND SETTINGCohort study and quality improvement project; women who had delivered a baby or stillborn delivery over 24 weeks gestation METHODA retrospective pre-intervention clinical audit between April 2022 and March 2023 evaluated the service delivery performance of maternal postnatal 6WC. Implementation of a model of access with protected postnatal appointments and proactive invitation via SMS was introduced in April 2024. Post-intervention audit evaluated the interventions performance after 12 months. RESULTSPre-intervention audit showed 58% (70/121) of eligible women had a maternal 6WC and 60% (42/70) were performed within 6-8 weeks after delivery. Following the introduction of the intervention, 98% (112/114) of eligible women were offered a postnatal check appointment. After 12 months, the uptake of maternal postnatal checks improved from 58% to 89% (101/114) and appointments performed within 6-8 weeks improving from 60% to 76% (77/101). The uptake of newborn checks improving from 86% to 91% (106/116) and appointments performed within 6-8 weeks improving from 46% to 75% (80/106). CONCLUSIONWe implemented protected postnatal appointments with proactive invitation via SMS and demonstrated a sustainable improvement in practice service delivery over 12 months of implementation. The protocol required no additional workforce resources, had a low administrative burden and used digital communication tools easily available to general practices nationwide. Our intervention provides a model of access for the provision of postnatal care in general practice to reduce inequality and inequity in healthcare.

BackgroundPrimary care practitioners are well-positioned to support people of reproductive age in preparing for pregnancy and parenthood. Such "preconception care" is ideally delivered opportunistically during routine consultations, although limited time presents a barrier. AimTo achieve consensus on priority topics for opportunistic preconception care in general practice. Design and settingA three-step consensus study involving UK-based primary care practitioners and people of reproductive age. MethodThe consensus process involved: 1) identifying potential topics through literature and guideline reviews, workshops with people of reproductive age (n=15), and interviews with primary care practitioners who work in general practice (n=14); 2) prioritising topics using a Delphi survey (n=85 participants completing round one, n=63 completing all three rounds); and 3) agreeing on priority topics during an online consensus workshop (n=21 participants). Participants were recruited through a Public Advisory Group, charities, and professional organisations. ResultsReviews and workshops/interviews with people of reproductive age and practitioners identified 37 potential topics. The Delphi survey and consensus workshop identified 16 priority topics. These were combined into four overarching topic areas for discussion during relevant consultations: O_LIPatient knowledge of preconception health and pregnancy C_LIO_LIIdeas, concerns and expectations (e.g. pregnancy intention, prior pregnancy experiences) C_LIO_LIHealth conditions (e.g. medication use, mental/physical health, immunisation) C_LIO_LIHealth behaviours (e.g. folic acid supplement use, smoking, alcohol consumption). C_LI ConclusionThe agreed priority topic areas offer a structured foundation for delivering patient-centred, opportunistic preconception care in primary care. The findings support future co-development of practical tools and resources to enable routine implementation. How this fits inPreconception care improves pregnancy outcomes, but in UK general practice it is inconsistently delivered, partly due to limited time and guidance that offers little prioritisation for opportunistic consultations. This study identifies four overarching topic areas for preconception care, based on consensus among people of reproductive age and primary care practitioners. The resulting priority list offers clinicians a practical, flexible way to initiate patient-centred preconception care discussions within routine consultations.

BackgroundThe World Health Organisations Medication Without Harm campaign aims to reduce severe avoidable medication related harm by 50%. This systematic review explored the characteristics of interventions that provide visual and longitudinal feedback on prescribing, or interactive dashboards, in general practice and the effect of these interventions on prescribing-related outcome measures. MethodsThis systematic review was registered prospectively and reported in line with PRISMA guidelines. Multiple databases and grey literature were searched in November 2023 to identify interventional studies that explored the effect of interactive dashboards on prescribing-related outcomes in general practice. Two independent researchers conducted screening, data extraction, and risk of bias assessment. Interventions were described narratively, and a random-effects meta-analysis was performed for comparable studies. ResultsEight randomised controlled trials, one controlled before-and-after study and three interrupted time series were included. Six studies reported a significant positive effect on prescribing-related outcomes, with an effect seen more often for studies focusing on potentially inappropriate prescribing (PIP) (four out of six). Two of the six studies that focused on antibiotic prescribing demonstrated a significant effect. A meta-analysis of three RCTs involving 160 general practices and 198,135 patients demonstrated the overall odds of PIP was 0.91 (95%CI: 0.77-1.06 I2=71.8%) in the intervention compared to control group. ConclusionInteractive dashboards show promise for supporting safe and effective prescribing in general practice. Future research should focus on developing core outcome sets to facilitate future meta-analyses of effectiveness as well as optimising their implementation and understanding how to sustain user engagement. Lay summaryThe World Health Organizations "Medication Without Harm" campaign aims to reduce preventable medication-related harm by 50%. One way to support safe prescribing is by giving prescribers ongoing feedback on their prescribing habits using interactive dashboards. These dashboards provide visual and long-term data to help guide safer and more effective prescribing. This research looked at how interactive dashboards have been used in general practice and whether their use improves prescribing. Researchers systematically searched the published literature and identified 12 relevant studies. Some studies involved randomly assigning doctors or practices to either use the dashboards or continue usual care. Others compared prescribing practices before and after introducing dashboards or looked at practices that used dashboards compared to those that did not. Six of the studies showed improvements in prescribing, especially when focused on reducing high-risk prescriptions. The data for three studies that looked at high-risk prescribing involving 160 general practices and 198,135 patients showed that interactive dashboards may reduce the chance of unsafe prescribing by 8.8%. However, this result was not statistically significant, and the difference in results between studies means the true effect remains uncertain. The findings highlight the potential of interactive dashboards to support safer prescribing in general practice, though further research is needed.

BackgroundThe COVID-19 pandemic has led to an ongoing increase in the use of remote consultations in general practice in England. Though the evidence is limited, there are concerns that the increase in remote consultations could lead to more antibiotic prescribing. MethodsWe used patient-level primary care data from the Clinical Practice Research Datalink to estimate the association between consultation mode (remote vs face-to-face) and antibiotic prescribing in England for acute respiratory infections (ARI) between April 2021 - March 2022. We used targeted maximum likelihood estimation, a causal machine learning method with adjustment for patient-, clinician- and practice-level factors. FindingsThere were 45,997 ARI consultations (34,555 unique patients), of which 28,127 were remote and 17,870 face-to-face. For children, 48% of consultations were remote whereas for adults 66% were remote. For children, 42% of remote and 43% face-to-face consultations led to an antibiotic prescription; the equivalent in adults was 52% of remote and 42% face-to-face. Adults with a remote consultation had 23% (Odds Ratio (OR) 1.23 95% Confidence Interval (CI): 1.18-1.29) higher chance of being prescribed antibiotics compared to if they had been seen face-to-face. We found no significant association between consultation mode and antibiotic prescribing in children (OR 1{middle dot}04 95% CI 0{middle dot}98-1{middle dot}11). InterpretationThis study uses rich patient-level data and robust statistical methods and represents an important contribution to the evidence base on antibiotic prescribing in post-COVID primary care. The higher rates of antibiotic prescribing in remote consultations for adults are cause for concern. We see no significant difference in antibiotic prescribing between consultation mode for children. These findings should inform antimicrobial stewardship activities for health care professionals and policy makers. Future research should examine differences in guideline-compliance between remote and face-to-face consultations to understand the factors driving antibiotic prescribing in different consultation modes. FundingNo external funding. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSUse of remote consultations in general practice has increased rapidly since the onset of the COVID-19 pandemic. Concerns have been raised that antibiotic prescribing rates may be higher in remote compared with face-to-face consultations. Acute respiratory infection (ARI) is the most common reason for an antibiotic prescription in adults making it one of the most important areas of prescription practice for antibiotic use. Empirical studies investigating the differences in antibiotic prescribing rates between online and remote consultations have produced mixed findings, in general and for ARIs specifically. Recent review-type articles on the topic - including a 2020 qualitative systematic review and a 2021 meta-analytic systematic review - have reported mixed results when comparing online and face-to-face consultations with some showing higher and others lower antibiotic prescribing in remote consultations. Furthermore, many of the studies that were included in the reviews were at risk of bias due to a failure to control for demographic and clinical differences between patients in remote versus face-to-face consultations. Added value of this studyThis is the first England wide study estimating the difference in antibiotic prescribing between consultations modes in the post-covid setting where remote consultations are as common as face-to-face consultations. It is also the first study in this setting to apply TMLE - doubly robust causal machine learning method. We found that an adult was 23% more likely to be prescribed an antibiotic for an ARI in a remote compared with a face-to-face consultation with a general practitioner in England. There was no evidence for a difference in children. Our findings are based on an analysis of a representative sample of almost 46,000 GP consultations for ARIs in general practice in England and controls for patient-, clinician- and practice-level factors that are associated with both consultation mode and with antibiotic prescribing. As such, our findings are at a smaller risk of bias from unobserved confounding than the previous research examining this issue and therefore represent an important contribution to the evidence base. Implications of the available evidenceTaken together with the existing body of evidence on this topic, our results showing higher prescribing in remote consultations are cause for concern. The factors affecting antibiotic prescribing and the interaction with consultation mode are complex and will require further research to unpick. The existing evidence including this study have largely focused on prescribing rates, and do not investigate the appropriateness of antibiotics prescribing in remote compared to face-to-face consultations. Further investigation is required to explain the discrepancy between consultation modes. The growing body of evidence in this area has relevance for future antimicrobial stewardship activities and should be used to inform the ongoing development of antibiotic prescribing guidelines for remote consultations.

BackgroundGP practices in Scotland are changing with the emergence of megapractices. We aimed to update analyses of GP practice sizes in Scotland, and to begin the development of a typology of GP practices. MethodsFour methods were employed: 1. Analyses of routinely published data on GP practice sizes and listed GPs to identify and quantify megapractices; 2. Qualitative interviews; 3. Creation of commercial profiles; 4. Derivation of a GP practice typology. ResultsMost Scottish practices have less than 9,000 patients, but five megapractices with over 30,000 patients were identified. One had grown by over 18,000 patients in two years to almost 120,000 patients, with the next largest at almost 73,000 patients. Megapractices did not engage with interviews, but commercial profiling revealed an array of complex legal and financial arrangements for several of them. We suggest that the key parameters for describing practices should focus on: ownership, legal status and motives; the extent of service provision by doctors or Allied Health Professionals (AHPs); and practice list size. We tentatively propose four common practice types in Scotland: traditional practices, megapractices, social enterprise practices, and direct NHS provision, recognising substantial diversity amongst megapractices. ImplicationsPolicymakers should carefully consider the risks of the current drift in approach to GP provisioning. Evaluation of the impacts of new service models on healthcare access, health outcomes and inequalities is urgently needed.

BackgroundReal-world evidence to support the adoption of SARS-CoV-2 point-of-care (POC) tests in primary care is limited. As the first point of contact of the health system for most patients, POC testing can potentially support general practitioners (GPs) quickly identify infectious and non-infectious individuals to rapidly inform patient triaging, clinical management, and safely restore more in-person services. ObjectivesTo explore the potential role of SARS-CoV-2 point-of-care testing in primary care services. DesignA qualitative study using an inductive thematic analysis. Setting21 general practices located across three regions in England. ResultsThree major themes were identified related to POC test implementation in primary care: (1) Insights into SARS-CoV-2 POC tests; (2) System and organisational factors; and (3) Practice-level service delivery strategies. Thematic subcategories included involvement in rapid testing, knowledge and perception of the current POC testing landscape, capacity for testing, economic concerns, resource necessities, perception of personal risk and safety, responsibility for administering the test, and targeted testing strategies. ConclusionGPs knowledge of POC tests influences their degree of trust, uncertainty, and their perception of risk of POC test use. Concerns around funding, occupational exposure, and workload play a crucial role in GPs hesitation to provide POC testing services. These concerns could potentially be addressed with government funding, the use of targeted testing, and improved triaging strategies to limit testing to essential patient cohorts.

BACKGROUNDWhile decision aids have been proven effective to facilitate patient-centered discussion about evidence-based health information in practice and enable shared decision making (SDM), a chasm remains between the promise and the use of these SDM tools in practice. AIMSTo promote evidence-based patient-centered care in primary care by using encounter SDM tools for medication management of chronic conditions. METHODSWe conducted a mixed methods study centered around a practice-based, multi-centered pragmatic randomized trial comparing active implementation (active) to passive dissemination (passive) of a web-based toolkit, ShareEBM, to facilitate the uptake in primary care of four SDM tools designed for use during clinical encounters. These tools supported collaborative decisions about medications for chronic conditions. ShareEBM included activities and tactics to increase the likelihood that encounter SDM tools will be routinized in practice. Study team members worked closely with practices in the active arm to actively integrate and promote the use of SDM tools; passive arm practices received no support from the study team. The embedded qualitative evaluation included clinician phone interviews (n=10) and site observations (n=5) for active practices, and exit focus groups for all practices (n=11). RESULTSEleven practices and 62 clinicians participated in the study. Clinicians in the active arm used SDM tools in 621 encounters (Mean [SD]: 21 [25] encounters per clinician, range: 0-93) compared to 680 in the passive arm (Mean [SD]: 20 [40] encounters per clinician, range: 0-156, p=0.4). Six of 29 (21%) clinicians in the active arm and 14 of 33 (42%) in the passive arm did not use any tools (p=0.1). Clinicians views covered four major themes: general views of using encounter SDM tools, perceived impact on patients, strategies used, and how encounter SDM tools are incorporated into practice flow. CONCLUSIONNeither active nor passive implementation of a toolkit improved the uptake and use of encounter SDM tools in primary care. Overcoming clinician reluctance to consider using encounter SDM tools, their seamless integration into the electronic and practice workflows, and ongoing feedback about the quality of their use during encounters appear necessary to implement their use in primary care practices.

1.BackgroundType 2 diabetes (T2D) is a leading cause of both chronic kidney disease (CKD) and onward progression to end stage renal disease. Timely diagnosis coding of CKD in patients with T2D could lead to improvements in quality of care and patient outcomes. AimTo assess the consistency between estimated glomerular filtration rate (eGFR) based evidence of CKD and CKD diagnosis coding in UK primary care. Design and SettingA retrospective analysis of electronic health record data in a cohort of people with type 2 diabetes from 60 primary care centres within England between 2012 and 2022. MethodWe estimated the incidence rate of CKD per 100 person-years using eGFR-based CKD and diagnosis codes. Logistic regression was applied to establish which attributes were associated with diagnosis coding. Time from eGFR-based CKD to entry of a diagnosis code was summarised using the median and interquartile range. ResultsThe overall incidence of CKD was 2.32 (95% CI: 2.24, 2.41) and significantly different between eGFR-based criteria and diagnosis codes: 1.98 (95% CI: 1.90, 2.05) vs 1.06 (95% CI: 1.00, 1.11) respectively; p<0.001. Only 46% of CKD incidences identified using eGFR-based criteria had a corresponding diagnosis code. Younger patients, patients with a higher severity CKD stage, and patients with an observed urine-albumin-to-creatinine ratio were more likely to have a diagnosis code. ConclusionDiagnosis coding of patients with eGFR-based evidence of CKD in UK primary care is poor within patients with type 2 diabetes, despite CKD being a well-known complication of diabetes. 2. How this fits inType 2 diabetes is a recognised cause of chronic kidney disease (CKD), and early identification and management of CKD can reduce the risk of progression and related complications. Diagnosis coding of CKD is associated with better patient outcomes, yet we have observed that less than half of patients with type 2 diabetes who meet eGFR-based criteria for stage 3-5 CKD have a CKD diagnosis code in their primary care record. There is a need to understand why CKD diagnosis coding practices are subpar in primary care and this research acts as a call-to-action to improve.

AimsTo estimate the prevalence of potentially inappropriate prescriptions (PIPs) in patients starting their first non-insulin antidiabetic treatment (NIAD) using two explicit process measures of the appropriateness of prescribing in UK primary care, stratified by age and polypharmacy status. MethodsA descriptive cohort study between 2016 and 2019 was conducted to assess PIPs in patients aged [&ge;]45 years at the start of their first NIAD, stratified by age and polypharmacy status. The American Geriatrics Society (AGS) Beers criteria 2015 was used for older ([&ge;]65 years) and the Prescribing Optimally in Middle-age Peoples Treatments (PROMPT) criteria for middle-aged (45-64 years) patients. Prevalence of overall PIPs and individual PIPs criteria was reported using the IQVIA Medical Research Data incorporating THIN, a Cegedim Database of anonymised electronic health records in the UK. ResultsAmong 28,604 patients initiating NIADs, 18,494 (64.7%) received polypharmacy. In older and middle-aged patients with polypharmacy, 39.6% and 22.7%, respectively, received [&ge;]1 PIPs. At the individual PIPs level, long-term PPI use and strong opioid without laxatives were the most frequent PIPs among older and middle-aged patients with polypharmacy (11.1% and 4.1%, respectively). ConclusionsThis study revealed that patients starting NIAD treatment receiving polypharmacy have the potential for pharmacotherapy optimisation.