British Journal of General Practice

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.

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.

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.

Objective The aim of this study was to develop and validate an automated, scalable framework to harmonise fragmented UK primary care prescription records into a research-ready dataset by mapping four diverse medical ontologies to a unified, historically comprehensive reference standard. Materials and Methods We used raw prescription records for consented participants in the UK Biobank, in which participants are uniquely characterized by multiple data modalities. Primary care data were preprocessed by selecting one drug code if multiple were recorded, cleaning codes to match reference presentations, expanding code granularity based on drug descriptions, and updating outdated codes to a single reference version. Harmonisation entailed mapping British National Formulary (BNF) and Read2 codes to dm+d, the universal NHS standard vocabulary for uniquely identifying and prescribing medicines. Harmonised dm+d records were then homogenised to a single concept granularity, the Virtual Medicinal Product (VMP). We validated our methods by creating medication profiles mapping contemporary drug prescribing patterns in 312 physical and mental health conditions. Results We preprocessed 57,659,844 records (100%) from 221,868 participants (100%). Of those, 48,950 records were dropped due to lack of drug code. 7,357,572 records (13%) used multiple ontologies. Most (76%) records were encoded in BNF and most had the code granularity expanded via the drug description (N=28,034,282; 49%). 41,244,315 records (72%) were harmonised to dm+d and 99.98% of these were converted to VMP as a homogeneous dataset. Across 312 diseases, we identified 23,352 disease-drug associations with 237 medications (represented as BNF subparagraphs) that survived statistical correction of which most resembled drug - indication pairs. Conclusion Our methodology converts highly fragmented and raw prescription records with inconsistent data quality into a streamlined, enriched dataset at a single reference, version, and granularity of information. Harmonised prescription records can be easily utilised by researchers to perform large-scale analyses in research.

Social prescribing (SP) is growing rapidly in the United Kingdom and internationally. However, the evidence for its impact is still limited. Drawing pre-post data from longitudinal administrative records (n=4,547), this study aimed to investigate whether SP has the potential to reduce health service utilisation in both primary and secondary care settings. The outcomes were measured using self-reported GP visits, A&E attendances and hospital admissions in the last three months. Data were analysed using Bayesian growth curve modelling, with Poisson or hurdle lognormal models tailored to the specific outcome. Our findings demonstrate consistent patterns of reduced health service utilisation across all outcome measures and model components. Specifically, GP attendance decreased by an average of 1 visit per person (95% CI: -1.07 to -0.95) in three months following SP (53.1% reduction). A&E attendance decreased by 0.04 admissions per person (95% CI: -0.06 to -0.03), equivalent to a 62.6% reduction. And hospital admissions decreased by 0.03 admission per person (95% CI: -0.03 to -0.02), equivalent to a 61.7% reduction. We found limited evidence that the health service utilisation changes differ across socio-demographic groups, indicating a broad applicability of SP interventions.

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

BackgroundRoutinely collected prescribing and medicine-related data in Scotland are comprehensive and of high quality. However, they are generated across multiple healthcare settings and stored in complex source systems that are not optimised for longitudinal or outcomes-focused research. To maximise the research value of these data, there is a need for curated, analysis-ready resources that provide consistent representations of medicines exposure and enable linkage to clinical outcomes. The Medicines in Acute and Chronic care Scotland (MACCS) provides standardised, curated medicines data to support longitudinal analyses of medicine-related exposure across NHS healthcare systems. MethodsMACCS resource is a national individual-level medicines dataset for adults (18 years of age and older), derived from routinely collected prescribing and medicine-related data held by Public Health Scotland (PHS). It integrates data from the Hospital Electronic Prescribing and Medicines Administration (HEPMA), Prescribing Information System (PIS), and Homecare Medicines (HCM) datasets, which are linked at the individual level to eleven other national clinical records; including Scottish Morbidity Records (SMR00/01/02/04/06), laboratory data and mortality records; using the unique NHS Scotland person identifier. Data are curated, harmonised and pre-linked within the National Safe Haven and accessed by approved researchers through secure Trusted Research Environments. ResultsMACCS contains individual-level information on adults receiving NHS Scotland care, including patient demographics (such as age, sex and geographical indicators) and detailed records of medicines prescribing in community pharmacies as well as those administered in hospitals and through homecare services. Medicines-related data captures exposure dates and, where available, details on formulation, strength and dose. In addition, MACCS includes cancer registry data, renal registry data, laboratory test results, microbiology surveillance and mortality records. The earliest dates of data availability vary by source dataset. ConclusionMACCS provides a sustainable, longitudinal medicines research resource that simplifies access to complex national prescribing data and enables robust linkage to health outcomes. By supporting population-scale analyses across care settings, MACCS enhances the capacity for high-quality research to inform clinical practice, health policy, and medicines optimisation in Scotland. Key FeaturesO_LIThe Medicines in Acute and Chronic Care in Scotland (MACCS) data resource was established in 2025 to integrate medicine-related data with other electronic data from Scottish healthcare systems, creating a national, linked, routinely updated data resource at population level. C_LIO_LIMACCS provides pre-linked data from multiple routinely collected national datasets within NHS Scotland including, but not limited to, prescribing records, hospital episodes, laboratory results, and death records, within a single secure environment. C_LIO_LIMACCS includes patient demographics, data on medicines prescribing and administration/supply, key biochemistry and haematology test results (e.g., kidney and liver function tests), data on hospital admissions and surgical procedures, and date and cause of death. C_LIO_LIThe data resource provides longitudinal follow-up of the adult population ([&ge;]18 years of age) receiving medicines through NHS Scotland since 2010, covering approximately 4.6 million individuals, and supports pharmacoepidemiological studies, drug utilisation research, pharmacovigilance projects, as well as health services research. C_LIO_LIApproved researchers can apply through a streamlined process to access the linked MACCS data resource through established NHS Scotland governance processes, with data accessed within a Trusted Research Environment. C_LI

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

Abstract Background Between 2021 and 2022, primary care obesity management was entering the early diffusion phase of newer anti obesity pharmacotherapy, as GLP1 based treatments began reshaping expectations. However, it was unclear whether primary care clinicians and practice environments were prepared to deliver comprehensive obesity care. (1,2) Methods In 2021 to 2022, we surveyed 276 clinicians from three cohorts: an opt-in national physician panel (Cohort A), clinicians from an integrated health system (Cohort B), and clinicians from a rural accountable care organization (Cohort C). The survey, informed by formative patient and physician focus groups conducted in 2021, assessed current and desired competence, attitudes, confidence, perceived forces for change, and barriers to obesity care. Analyses were descriptive (means and standard deviations). Results Across cohorts, desired competence exceeded current competence. The largest gaps involved recommending behavioral interventions, developing comprehensive care plans, and providing ongoing obesity management support. Attitudes toward obesity care were generally favorable, while confidence that current practices reflected best practice was only moderate. Professional and personal forces for change were moderate, patient driven motivators were moderate to high, whereas social (peer/organizational) reinforcement was weak. Reported barriers extended beyond knowledge deficits to include patient engagement, competing demands, cost, and practical constraints. Conclusions At the threshold of the GLP1 era, primary care clinicians were motivated to improve obesity care but lacked consistent support to deliver comprehensive management. The relative absence of peer and organizational reinforcement suggests that readiness for change reflected not only individual knowledge and attitudes, but also the degree of peer and organizational reinforcement that supports comprehensive obesity care in routine practice.

BackgroundWithin the UK, more than a million people cannot speak English well or at all. The lack of data on English proficiency means that the link between English proficiency and health status and care utilisation is not comprehensively quantified. ObjectiveDescribe the association between English proficiency and patients health status and healthcare utilisation, and demonstrate that GP data can be useful in understanding the health burdens of those with poor language proficiency. MethodsThe Northwest London (NWL) Discover-NOW database contains linked, deidentified records from General Practices (GPs), hospitals, and social care in NWL. Using this data, we examined health outcomes and healthcare utilisation of people in Brent who are not proficient in English. ResultsPrevalence of age-sex-adjusted cardiometabolic conditions was higher in groups that were not proficient in English or spoke a main language other than English. Primary and secondary healthcare utilisation was also higher in groups that were not proficient in English. ConclusionThis work is the first to quantify healthcare utilisation of those not proficient in English using a large, representative sample in a UK setting. It highlights poorer health outcomes in this group. There is a need to improve provision of language support, starting at registration, which would allow for this group to be better understood.

ObjectivesEvaluate the impact of online symptom checker formats on symptom management knowledge, symptom checker trust and acceptability, and behavioural intentions. DesignTwo 5-arm parallel-group online randomised controlled trials. SettingOnline survey. Participants2110 Australian adults recruited through online research panel in June 2025. Almost half identified as man/male (49%) and woman/female (51%), median age 49 years (IQR=28). Participants viewed a hypothetical health scenario (fever and vomiting) followed by a screenshot of an online symptom checker from national health service provider, healthdirect. InterventionsParticipants were randomised to symptom acuity level (low: self-care at home; or moderate: see a General Practitioner (GP) in 24 hours) and one of five symptom checker formats. The standard format showed the existing healthdirect symptom checker advice. The remaining formats were AI-enhanced versions. These included an AI-enhanced version with e.g. more tailored advice, rationale for acuity level, and AI disclosure statement. The other AI-enhanced formats had additional features: numbered steps, multimedia, and more detailed information about the use of AI. Main outcome measuresPrimary outcomes were intentions to follow the symptom checkers self-care advice and intentions to see a GP in 24 hours. Secondary outcomes were trust in advice, knowledge of symptom management, and acceptability of the tool. All outcomes were assessed immediately post-intervention; knowledge was also assessed after 2 weeks. ResultsWhen advised to self-care at home, the AI-enhanced groups reported lower intentions to see a GP in 24 hours (median 3.00 out of 5), compared to the standard (original) tool (median 4.00; adjusted p = 0.003). There were no other significant effects on intentions. Immediately following the intervention, participants who viewed an AI-enhanced format reported greater knowledge about how to manage current and changing symptoms, across both acuity levels (adjusted ps <0.001). Knowledge gains were not sustained at 2 week follow-up. There were no significant effects on trust or acceptability. ConclusionsParticipants who viewed the more tailored information in the AI-enhanced formats demonstrated stronger knowledge for managing symptoms than those who viewed the standard format. There was also some evidence that an AI-enhanced format may be more effective at reducing use of primary care for symptoms that can be managed at home. Trust and acceptability were high across formats, and the explicit use of AI did not impact significantly on these outcomes. Future research should investigate these formats using interactive prototypes across a wider variety of health contexts. RegistrationACTRN ACTRN12625000474459p Key messagesO_LIWhat is already known on this topic: Although online, evidence-based symptom checkers have been widely available from reputable health organisations for over a decade, they often face poor uptake and may not adequately meet health literacy needs of diverse users. C_LIO_LIWhat this study adds: Symptom checker features that could be implemented with AI, such as tailored information and a clear rationale for triage advice, may help support appropriate symptom management. Statements about the tools use of AI did not appear to impact trust or acceptability of the symptom checker tool. C_LIO_LIHow this study might affect research, practice or policy: Findings from this study suggest that using AI to enhance symptom checker advice may not impact negatively on trust and acceptability of the tool, and may improve appropriate symptom management. Further research is needed to investigate AI-enhanced symptom checker formats using interactive prototypes across a wider variety of health contexts. C_LI

BackgroundMedication shortages are a considerable and ongoing issue in healthcare, disrupting consumer access. Since 2021, Australias national medicines regulator has issued Serious Scarcity Substitution Instruments (SSSIs), allowing pharmacists to substitute a specific therapeutically equivalent strength and/or formulation of a medicine without prior approval from a prescriber. The impact of SSSIs on utilisation of medicines has not been investigated. ObjectiveDetermine whether SSSIs are effective in addressing medicine shortages and meeting patient need. MethodsThis retrospective cohort study used aggregated pharmacy claims to examine the utilisation of 12 medicines which had an SSSI. We calculated the percentage change in defined daily doses dispensed per 1000 population per day in the 11 months after SSSI implementation, compared with the previous two years. A percentage change of less than 20% was used to indicate success. ResultsFollowing product shortages, utilisation fell for 10 of the 12 medicines examined. For eight of these medicines (amoxicillin, cefalexin, estradiol, fluoxetine, insulin degludec with insulin aspart, isosorbide mononitrate, vigabatrin, and warfarin) decreases in utilisation were minimised to <20%. On average, SSSIs where all permitted substitute products were scarce (e.g. abatacept) were associated with larger decreases in use (between -22% and -68%) than those for which none or only some of the substitutes were in shortage (between -45% and +7%, respectively). ConclusionsWhile product shortages led to decreases in medicines consumption, SSSIs appeared to be successful in limiting decreases. However, SSSIs were less likely to be successful when many of the permitted substitute products were also scarce. Key pointsO_LIThis study is the first to evaluate the effectiveness of Australias Serious Scarcity Substitution Instruments (SSSIs) in mitigating medicine shortages using national dispensing data and interrupted time series analysis. C_LIO_LITwo-thirds of SSSIs successfully limited utilisation declines to less than 20%, with effectiveness strongly linked to the availability of substitute products. C_LIO_LIBy demonstrating variable utilisation outcomes across medicines, this study adds empirical evidence to international debates on substitution policies, suggesting that nationally standardised frameworks like Australias SSSIs may function best when supported by robust supply intelligence. C_LIO_LISSSIs are a valuable policy tool for maintaining continuity of care during shortages, but timely implementation and ensuring substitute supply are critical for optimal impact. C_LI

Background Advice and Guidance (A&G) enables primary care clinicians to seek specialist input, supporting decision making and avoiding unnecessary referrals. The use of A&G has significantly expanded, accelerated by COVID19 and contractual changes. While A&G is intended to streamline elective care, concerns persist regarding workload shift, variable responsiveness, and system usability. Despite growing policy emphasis, little is known about why clinicians choose to use A&G. Aim Explore the current use of A&G within primary care, focusing on decision making processes which underpin PCCs' decision to use A&G. Design and Setting Qualitative study set in English Primary Care Method Twenty semi structured video interviews were conducted with primary care clinicians purposively sampled for maximum variation. Topic guides were developed with PPIE input and refined iteratively. Data were analysed using reflexive thematic analysis within an interpretive description framework, with themes developed collaboratively and refined through discussion with researchers and PPIE contributors. Ethical approval was obtained (REC 333799). Results Four overarching themes encapsulate clinicians' decisions to use A&G: clinical presentation (acuity and complexity), navigating healthcare pathways, previous experiences of A&G, and using A&G to validate clinical decision making. Barriers included delayed responses and uncertainty about inequitable workload distribution. These factors shape how effectively A&G could be integrated into routine practice. Conclusion Primary care clinicians use A&G to support patient care and aid decision-making, but its effectiveness depends on timely, clinically helpful responses. Ensuring responses remain appropriate to primary care remit and capacity will be essential if A&G becomes the main route into elective care.

BackgroundRecurrent sore throat affects a small minority of adults but can cause substantial morbidity. Evidence to guide tonsillectomy eligibility in adults is limited, and current criteria are extrapolated from paediatric populations. We aimed to describe the epidemiology, management, and prognosis of adult sore throat in UK primary care. MethodsUsing CPRD Aurum (2010-2020 adults with a first coded episode of sore throat or tonsillitis were identified and matched to controls. Episode frequency, antibiotic use, ENT referral, and tonsillectomy were analysed. Predictors of recurrent episodes ([&ge;]3 in 365 days), referral, and tonsillectomy were assessed using time-to-event, multinomial logistic, and multilevel mixed-effects regression models. FindingsOf 4.45 million adults, 1.70 million (38.3%) had [&ge;]1 episode; most (61.5%) had only one, but 4.1% experienced [&ge;]3 within 1 year. Recurrent episodes were more common in younger females and those from more deprived areas. Only 21,869 patients (0.5% of the exposed cohort) underwent tonsillectomy, and just 25.7% of these met Paradise criteria at any time; conversely, only 13.9% of those meeting criteria underwent surgery. Patients who had a tonsillectomy tended to be younger, female, and from less deprived areas. Pre-tonsillectomy episode rates were unexpectedly low, but the data indicated that individuals with high baseline burden continue to experience elevated episode rates over several years. ConclusionsRecurrent sore throat is uncommon, but those affected face substantial disease burden. Current tonsillectomy patterns are poorly aligned with disease burden and show inequities by deprivation. Earlier identification of adults likely to develop recurrent episodes, and more timely surgical intervention, may improve patient outcomes and the cost-effectiveness of tonsillectomy.

ObjectivesAn update to the NICE Type 2 diabetes (T2DM) guideline in February 2022 recommended an SGLT2 inhibitor be offered to people with cardiovascular disease (CVD) or heart failure (HF) as comorbidities and considered for people at high CVD risk. We report uptake of this guideline in England 18 months after its publication. DesignObservational cohort study. SettingGeneral practices contributing to the Clinical Practice Research Data Link, linked to hospital admission records. Participants587,826 people aged over 18 years with T2DM on 1st September 2023, stratified according to their CVD category (CVD only; HF only; CVD and HF; high CVD risk score; low CVD risk score) and chronic kidney disease (CKD) status, and further by age, gender, ethnicity, deprivation, and T2DM diagnosis duration. Main outcome measuresPercentage of patients with a current SGLT2 inhibitor prescription; odds ratios for association between patient characteristics and a current prescription. ResultsIn people with T2DM, the percentage with a current SGLT2 inhibitor prescription was 19.5% for people with CVD, 29.4% for people with HF, 30.5% for people with both CVD and HF, and 19.9% and 20.2% respectively for people at high and low CVD risk. In age-stratified analyses, uptake ordered from lowest to highest was as follows: low CVD risk score, high CVD risk score, CVD only, HF only, CVD and HF. In models adjusted for clinical and patient characteristics uptake was lower in people aged >60, women, Black people, and people living in areas of higher deprivation. ConclusionsWhilst prescribing of SGLT2 inhibitors continues to rise in England, an opportunity remains to increase uptake and to reduce inequalities in people with T2DM in 2026. We report inequalities by ethnicity and deprivation, and lower uptake for people with CVD without HF than people with HF, despite an equal guideline recommendation for these two groups. Additional evidence is needed on the effectiveness of SGLT2 inhibitors in frailer populations. What is already known on this topic?O_LIIn 2020 approximately 10% of people with type 2 diabetes (T2DM) and cardiovascular disease (CVD) and 14% of people with T2DM but without CVD in England had a current SGLT2 inhibitor prescription. C_LIO_LIIn February 2022 NICE recommended that an SGLT2 inhibitor should be offered to people with T2DM with heart failure or CVD, and considered for people with T2DM at high risk of CVD; network meta-analyses have found 10% to 40% lower odds of cardiovascular mortality with treatment in these groups. C_LIO_LIUptake of NICE guidelines in general practice has historically been variable, although higher when accompanied by pay-for-performance schemes such as the Quality and Outcomes Framework. C_LI What this study addsO_LIBy September 2023 the percentage of people with T2DM with a current SGLT2 inhibitor prescription had reached 19.5% in those with CVD as a comorbidity, 30.5% in those with heart failure, and 19.9% in those at high risk of CVD. C_LIO_LIWomen, people of Black ethnicity, and people living in areas of high deprivation had lower odds of a current prescription in analyses adjusted for age, gender, cardiovascular comorbidity, and renal function. C_LI How might these results change the focus of research or clinical practice?O_LIThe results highlight the need for ongoing surveillance of uptake of NICE-recommended treatments for T2DM, and consideration of actions to address barriers to uptake. This is particularly important in the context of broader eligibility for SGLT2 inhibitor treatment in type 2 diabetes in England from 2026. C_LIO_LIThese results support the development of initiatives and quality improvement programmes to improve evidence-based prescribing and address inequalities between clinical and demographic subgroups. C_LI

BackgroundChildhood overweight is a major health concern with long-term consequences. Dutch guidelines recommend that general practitioners (GPs) screen for overweight in children regardless of visit reason, yet GPs infrequently initiate weight-related conversations. ObjectivesTo explore what determines GPs initiation of conversations about childhood overweight, identify the determinants with the highest potential for change, and examine how, in particular, emotional responses and equanimity, relate to GPs intention to initiate conversations. MethodsA cross-sectional survey was conducted among Dutch GPs (in training) between March-May 2025. Behavioural determinants, based on the Theoretical Domains Framework, emotional responses, equanimity, and anticipated behaviour and implementation success were assessed. For all determinants, room for improvement (deviation from maximum), relevance (correlation with anticipated behaviour), and the potential for change (combining these two) were calculated using R. Open-ended responses were analysed using content analysis. Results57 GPs completed the survey. Most reported adequate skills (66%), knowledge (61%), and motivation (74%); yet only 25% reported high implementation success. Their behaviour is constrained by a lack of habituation, negative outcome expectancies, failing to remember to act, and a lack of social and organizational support. Emotional responses were evident, with 10-15% of respondents reporting high arousal or clearly positive or negative valence. Valence, but not arousal or equanimity, was positively associated with anticipated intention (r = 0.45, p < 0.001). ConclusionSupporting routine weight-related conversations requires strategies to strengthen habit formation, reshape outcome expectancies, support memory, address social and organizational factors, and further explore GPs emotion regulation. Key messagesO_LIAlthough highly motivated, general practitioners infrequently initiate conversations about childhood overweight due to existing practical barriers and barriers related to internal processes. C_LIO_LIHabit formation showed the greatest potential for change, emphasizing the importance of automaticity in initiating conversations. C_LIO_LIRegulation of emotions and outcome expectancies, may support GPs in consistently initiating sensitive weight-related conversations. C_LI

ObjectivesThe cancer diagnostic process may be more complicated for patients with a learning disability ("intellectual disability" outside of the UK) than for other patients. We aimed to investigate whether patients with a learning disability were more likely to experience disadvantage in cancer diagnostic pathways and outcomes. DesignA retrospective cohort study using routinely collected linked data across primary and secondary care, and cancer registration. Setting1470 general practices in England. Participants277,050 participants who were aged 40+ years, had an incident cancer recorded in the cancer registration during 2012-2018 and were registered for at least three years at their general practice prior to diagnosis. Main outcome measuresEmergency presentation route to diagnosis or urgent suspected cancer referral route to diagnosis, cancer stage at diagnosis (early vs advanced) and all-cause mortality within 30 days after diagnosis. Results277,050 patients were included in the study, with 796 (0.3%) patients having a record of a learning disability. Patients with a learning disability were over twice as likely to be diagnosed via an emergency presentation (aOR:2.65, 95%CI:2.26-3.11, p<0.001), and half as likely to be diagnosed via an urgent suspected cancer referral (aOR:0.51, 95%CI:0.43-0.60, p<0.001). They were also more likely to be diagnosed with advanced-stage cancer (aOR:1.37, 95%CI:1.12-1.67, p=0.002), especially for breast cancer, and to die within 30 days of diagnosis (aOR:3.77, 95%CI:3.10-4.59, p<0.001) than patients without a learning disability. ConclusionsPatients with a learning disability experience marked inequalities in cancer diagnostic pathways and outcomes. The increased risk of advanced-stage breast cancer is of particular note. Improved support to access and navigate the health care system may be required to negate experienced difficulties during the diagnostic process. Summary boxO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIPatients with learning disabilities experience avoidable mortality after a cancer diagnosis. C_LIO_LIGreater dependence on others, low symptom awareness and difficulties accessing and navigating the health care system during the cancer diagnostic process potentially contribute to worse outcomes, particularly for more severe learning disability. C_LI What this study addsO_LIConsidering all cancer sites except non-melanoma skin cancer, we found that having a record of a learning disability was associated with an increased likelihood of being diagnosed at an advanced stage, especially for breast cancer, and increased mortality within 30 days after diagnosis. C_LIO_LIPatients with a learning disability were more likely to be diagnosed as an emergency, and less likely to be diagnosed via an urgent suspected cancer referral. C_LI How this study might affect research, practice or policyO_LIPatients with a learning disability require better support to negate existing inequalities in diagnostic pathways and outcomes C_LI

Background Rural populations face disproportionate barriers to healthcare access, often due to geographic isolation and limited provider availability. Prior studies have shown that increased travel time negatively affects appointment adherence. Telemedicine has emerged as a potential solution, but understanding its utilization in rural populations remains ongoing. Methods This retrospective cross-sectional observational study analyzed all scheduled appointments (n=5,548) from a single rural family medicine clinic in the Pacific Northwest United States during 2024. One-way travel times were calculated using the Google Maps Distance Matrix API and categorized into Short (<15 minutes), Medium (15-30 minutes), and Long (>30 minutes) commute groups. Proportions for utilization and cancellations of both telemedicine and in-person appointments were assessed across commute groups using chi-square tests (p < 0.05 considered significant). Results Overall, the proportion of cancellations were significantly higher among patients with Long commutes (36.2%) compared to Medium (31.0%) and Short (32.2%) commute groups (p < 0.001). Telemedicine utilization increased proportionately with commute time (7.7% for Long commute patients vs. 1.5% for Short; p < 0.001). However, telemedicine cancellation proportions did not significantly differ across groups (21.2% for Long, 13.3% for Medium, 17.0% for Short; p = 0.122), suggesting comparable telemedicine adherence regardless of distance. The proportions for in-person appointment utilization and cancellation were both greatest for the Short commute group. Conclusion Longer travel times are associated with increased appointment cancellations for rural patients, reinforcing travel burden as a key barrier to care. Telemedicine use increases with commute distance and demonstrates consistent adherence across groups, indicating its value as a tool to address rural healthcare gaps. These findings support the continued expansion of telehealth infrastructure to improve care for geographically isolated populations.

BackgroundHypertension is a major modifiable risk factor for cardiovascular disease, yet blood pressure (BP) control remain suboptimal, particularly in socially disadvantaged communities. Guidelines recommend initiating single-pill combination (SPC) therapy to improve adherence and BP control, but uptake in primary care is limited. ObjectivesTo evaluate the SOLO care improvement project, promoting SPC initiation among general practitioners (GPs) in Amsterdam Zuidoost, a disadvantaged, multi-ethnic community in The Netherlands with a high hypertension burden. MethodsIn a cluster quasi-randomized cluster design, adult hypertensive patients from nine general practices within one health facility were allocated to intervention (IC; n=5) or usual care (UC; n=4). Intervention practices received case-specific guidance on SPC therapy. Outcomes were SPC uptake, changes in systolic and diastolic BP (SBP and DBP), target BP achievement and cardiovascular events. Analyses used intention-to-treat adjusted regression and Cox models, with additional as-treated analysis among SPC users. ResultsAmong 438 patients (mean age 64.5{+/-}12.2 years; median follow-up of 367 days [213-467]), SPC initiation was higher in the IC than US (25.1% vs. 9.6%, p<0.001). SBP/DBP decreased by -15.7/-6.9 mmHg in the IC and -10.4/-4.6 mmHg in the UC. Target BP was more often achieved in the IC (57.3% vs. 48.1%; OR: 1.4, 95%CI:1.0-2.1). Among SPC users, SBP/DBP decreased by -22.4/-10.5 mmHg. ConclusionPromoting SPC therapy improved blood pressure control, supporting local, targeted implementation as a pragmatic strategy to enhance hypertension management. Summary box, bullet points- In the SOLO care improvement project, SPC initiation was increased and improved blood pressure control in routine primary care. - The real-world implementation and cluster-based comparison enhanced practical relevance and reduced contamination between practices. - Although conducted in a large community health center, generalizability cannot be assumed; the non-blinded, non-randomized design allows residual confounding.

BackgroundPlatelet count and C-reactive protein (CRP) are blood tests commonly used in primary care as part of diagnostic work up for symptomatic patients. Abnormal results of these tests can indicate an undetected cancer; however, it is not known whether the association between an abnormal test result and cancer risk varies by patient ethnicity. MethodsThis cohort study used routinely collected primary and secondary health care records in England with linkage to national cancer registry data. Included patients had a record of ethnicity, no prior malignancy, a platelet count or CRP record between 1st January 2010 and 31st December 2017, and were aged 40 years or over at the time of that test. Ethnicity was categorised as White, Asian, Black, Other, and Mixed. Multi-level logistic regression models estimated cancer incidence within one-year of testing, adjusted for age, sex, comorbidities, BMI, deprivation, and year of test. ResultsAmong 4,948,342 patients with a platelet record and 811,559 with a CRP record, one-year cancer incidence was highest among White patients and lowest among Asian patients. Following a normal platelet count, cancer incidence was 1.3% (95% CI 1.3-1.3%) for White patients and 0.63% (0.60-0.66%) for Asian patients; following thrombocytosis, incidence increased to 4.1% (4.0-4.2%) and 1.8% (1.5-2.0%), respectively. After a normal CRP result, cancer incidence was 1.5% (1.4-1.5%) for White patients and 0.79% (0.71-0.88%) for Asian patients, rising to 3.6% (3.5-3.7%) and 1.9% (1.7-2.2%) for a high CRP result, respectively. No significant interactions were found between ethnicity, blood test result, and overall cancer diagnosis, and similar diagnostic odds ratios (dOR) were observed across all ethnic groups. However, for colorectal cancer, Black patients with abnormal results showed higher diagnostic odds ratios (dOR) compared with White patients, relative to a normal result. The dOR for thrombocytosis was 11.1 (7.8-15.6) for Black patients versus 5.7 (5.4-6.0) for White patients (interaction p-value <0.001), and for raised CRP was 4.1 (2.6-6.6) for Black patients versus 2.5 (2.3-2.7) for White patients (interaction p-value=0.043). ConclusionThis large primary care study underscores the need for ethnically diverse cohorts when evaluating diagnostic tests to avoid widening healthcare inequalities.