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.

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.

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

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.

Background In 2024, one-third of GP appointments in England were conducted by telephone. What happens during these consultations is largely unknown. Aim To test the feasibility of collecting recorded GP telephone consultations with linked data and consent for future research use. Design and setting Retrospective observational study in seven practices in South West England. Method Adults who had a telephone consultation at practices that routinely record calls were invited to consent to retrieval of call audio, a 4-month electronic health record (EHR) extract and a post-consultation patient questionnaire. Practice-level consent rates were analysed using regression models. Results Of 28 clinicians recruited, 19 GPs had consultations with patients whose recordings were retrievable, usable, and consented for future research. Of 2,053 invitations, 123 patients consented (6.0%). Consent was lower in more deprived practices (IMD 1-2 vs 9-10: OR=0.22, 95CI=0.09-0.54). Of 101 recordings retrieved, 96 were usable and 91 had consent for future research. 86/91 were linked to EHRs and 89/91 to post-consultation patient questionnaires. Mean consultation duration was 7 minutes 13 seconds; audible typing was heard in 69% (63/91). 161 problems were discussed (mean 1.77 per consultation). Most patients were happy their consultation was by telephone (96/117, 82%), although the majority reported usually preferring face-to-face appointments (68/115, 59%). Conclusion It is feasible to assemble a reusable archive of GP telephone consultations with linked data. However, recruitment was low using retrospective remote consent. Future work should test alternative recruitment approaches, particularly to improve patient engagement at practices serving deprived populations.

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

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.

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

ObjectiveTo examine the relationship between ethnicity and experiences of primary care for people with multiple long-term conditions (MLTCs) and assess the relative importance of demographic, practice, and area-level factors as influences on primary care experiences across ethnic groups. DesignA retrospective study using 2018-19 GP Patient Survey data linked to the General Practice Workforce data, and the Office for National Statistics data. SettingUK Participants: 294,987 respondents with two or more long-term conditions with complete data on selected demographic variables (age, gender, ethnicity, economic activity), practice and area-level variables (number of full-time equivalent GPs and nurses, practice size, area-deprivation, area life expectancy and ethnic density). Main outcome measuresMultilevel regression analysis used to assess the relationship between ethnicity and experience of accessing primary care (i.e. satisfaction with appointment times, types and booking experience) and interacting with healthcare professionals (i.e. satisfaction with confidence and trust in healthcare professionals and the extent to which patients feel healthcare professionals listen to them, give them enough time, treat them with care and concern, involve them in healthcare decisions, and meet their needs). Separate regression models built for each outcome and included i) each covariate separately, ii) demographic factors (iii) demographic, practice, and areal-level factors. ResultsUpon full adjustment Arab, Bangladeshi, Chinese, Indian, Pakistani, other Asian, mixed white and Asian, other white and other ethnic group people with MLTCs have both lower levels of satisfaction with primary care access and interacting with healthcare professionals compared with white British people. The influence of demographic, practice and area-level factors is not uniform across ethnic groups. For example, demographic factors account for the inequalities in levels of satisfaction with access to primary care between white British people and Black other, mixed other, mixed white & Black Caribbean and Gypsy & Irish Travellers. However, practice and area-level factors strengthen inequalities in the experience of accessing primary care for Bangladeshi, Indian and Pakistani people. ConclusionsGiven that patient experience is a key aspect of healthcare quality and is said to be associated with favourable health outcomes, the inequalities identified in this study are concerning. The poorer experiences of primary care might be one mechanism by which people with MLTCs from minoritised ethnic groups have poorer health outcomes. In addition to the assessment of other practice and area-level factors, qualitative studies are required to understand and effectively address the sources of ethnic inequalities in primary care experiences for people with MLTCs.

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 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.

BackgroundInteractive dashboards can support safe prescribing but effectiveness depends on user engagement. The research team developed a prescribing safety dashboard, deployed in 27 Irish general practices. Trend graphs tracked prescribing changes (2019-2025) by practices across key metrics. This study explored how GPs engaged with the dashboard and their perceptions of using routine data for prescribing feedback. MethodsPrescribers from participating practices were invited to online interviews (May-August 2025). A think-aloud exercise involved participants verbalising their thoughts while navigating the dashboards, followed by a semi-structured interview exploring views on safe prescribing, feedback and data access. Interviews were recorded, auto-transcribed and manually reviewed for accuracy. Think-aloud data were analysed deductively using a sense-making framework, interviews analysed inductively, and findings triangulated to refine themes. ResultsNine general practitioners (GPs) from eight practices participated. Themes were organised into four categories: (1) Perceptions of open data, (2) Perceptions of feedback, (3) Dashboard engagement, and (4) High-quality prescribing. Most were in favour of open data and transparency but some feared misuse. GPs valued feedback but reported workload as a barrier. Engagement with the dashboard was mainly interpretative, focused on data meaning in the context of their practice. GPs showed a strong emotional dimension to engagement and also described intended actions in response to what they saw. Finally, high-quality prescribing was mainly viewed as avoiding harm. ConclusionsGPs valued and engaged with dashboard feedback but workload competed with time for reflection and action-highlighting the need for practical, streamlined tools and nudges to support engagement. Key messagesO_LIAudit and feedback, such as that delivered through interactive dashboards has a small but significant effect on professional behaviours such as prescribing, but user engagement influences effectiveness. C_LIO_LIIrish GPs engaged with a prescribing safety and quality dashboard in a reflective and contextual way and garnered rich insights on their prescribing. C_LIO_LIGPs valued feedback and showed a strong emotional attachment to their performance, but felt workload competed with time for reflection and action. C_LIO_LIWith advances in data infrastructure, it is possible to provide interactive prescribing feedback in real time. However, the way feedback is designed and delivered plays a crucial role in supporting engagement. Dashboards and related behavioural interventions should be co-designed with prescribers to maximise engagement. C_LI

ObjectiveTo quantify the impact and recovery in cardiovascular disease monitoring in primary care associated with the first COVID-19 lockdown. DesignRetrospective nationwide primary care cohort study, utilising data from 1st January 2018 to 27th September 2020. SettingWe extracted primary care electronic health records data from 514 primary care practices in England contributing to the Oxford Royal College of General Practitioners Clinical Informatics Digital Hub (ORCHID). These practices were representative of English primary care across urban and non-urban practices. ParticipantsThe ORCHID database included 6,157,327 active patients during the study period, and 13,938,390 patient years of observation (final date of follow-up 27th September 2020). The mean (SD) age was 38{+/-}24 years, 49.4% were male and the majority were of white ethnicity (65% [21.9% had unknown ethnicity]) ExposureThe primary exposure was the first national lockdown in the UK, starting on 23rd March 2020. Main outcome measuresRecords of cholesterol, blood pressure, HbA1c and International Normalised Ratio (INR) measurement derived from coded entries in the primary care electronic health record. ResultsRates of cholesterol, blood pressure, HbA1c and INR recording dropped by 23-87% in the week following the first UK national lockdown, compared with the previous week. The largest decline was seen in cholesterol (IRR 0.13, 95% CI 0.11 to 0.15) and smallest for INR (IRR 0.77, 95% CI 0.72 to 0.81). Following the immediate drop, rates of recorded tests increased on average by 5-9% per week until 27th September 2020. However, the number of recorded measures remained below that expected for the time of year, reaching 51.8% (95% CI 51.8 to 51.9%) for blood pressure, 63.7%, (95% CI 63.7% to 63.8%) for cholesterol measurement and 70.3% (95% CI 70.2% to 70.4%) for HbA1c. Rates of INR recording declined throughout the previous two years, a trend that continued after lockdown. There were no differences in the times series trends based on sex, age, ethnicity or deprivation. ConclusionsCardiovascular disease monitoring in English primary care declined substantially from the time of the first UK lockdown. Despite a consistent recovery in activity, there is still a substantial shortfall in the numbers of recorded measurements to those expected. Strategies are required to ensure cardiovascular disease monitoring is maintained during the COVID-19 pandemic.

ObjectivesTo examine patterns of PCA reporting for informed dissent and patient unsuitable, how they vary by ethnic group, and whether ethnic inequities can be explained by socio-demographic factors or comorbidities. DesignA retrospective study using routinely collected electronic health records. SettingIndividual patient data from Clinical Practice Research Datalink collected from UK general practice. ParticipantsPatients with at least one of the 12 Quality and Outcomes Framework (QOF) conditions which had PCA coding options from a random sample of 690,00 patients aged 18+ years on the 1st of Jan 2016. Main outcomes measuresThe associations between ethnicity and two PCA reasons ( Informed Dissent and Patient Unsuitable) were examined using logistic regressions after adjustment for age, sex, multiple QOF conditions and area-level deprivation. ResultsThe association between ethnicity and the two PCA reasons were in opposite directions. After accounting for age, gender, multiple QOF conditions and area-level deprivation, people of Bangladeshi [OR: 0.69, 95% CI: 0.55 to 0.87], Black African [OR: 0.70, 95% CI: 0.61 to 0.81], Black Caribbean, OR: 0.67, 95% CI: 0.58 to 0.76], Indian [OR: 0.74, 95% CI: 0.66 to 0.83], mixed [OR: 0.86, 95% CI: 0.74 to 0.99], other Asian [OR: 0.74 95% CI: 0.64 to 0.86] and other ethnicity [OR: 0.66, 95% CI: 0.55 to 0.80] were less likely to have a PCA record for informed dissent than people of white ethnicity. Only people of Indian ethnicity were significantly less likely than people of white ethnicity to have a PCA record for patient unsuitable in fully adjusted models [OR: 0.80, 95% CI: 0.67 to 0.94]. We found ethnic inequities in PCA reporting for patient unsuitable among people of Black Caribbean, Black other, Pakistani, and other ethnicity, but these attenuated after adjusting for multiple QOF conditions and/or area level deprivation. ConclusionStudy findings counter the narratives that suggest that people from minoritised ethnic groups often refuse medical intervention. They illuminate the complex relationship between informed dissent and (dis)empowerment which requires further scrutiny. They also show ethnic inequalities in PCA reporting for patient unsuitable that are linked to clinical and social complexity and should be tackled to improve health outcomes for all.

BackgroundGeneral practitioners (GPs) adapted their work practices rapidly in response to the COVID-19 pandemic. Limited research has explored their perspectives over this time, and factors that may affect their wellbeing. MethodWe conducted a social media analysis of NHS GPs practising in the UK during the COVID-19 pandemic to identify issues which may affect their wellbeing. To identify trends, we assessed 91,034 tweets from 185 GPs on Twitter who posted before and during the pandemic, (January 2019 to February 2021). To identify themes related to wellbeing, we analysed qualitatively 7145 tweets posted during the pandemic from 200 GPs. ResultsWe identified inter-connecting themes that affect GP wellbeing, predominately around resources and support. Lack of personal protective equipment (PPE) and testing led to discussion of safety and risk, as well as increased workload resulting from staff isolating. Expressions of low morale and feeling undervalued were widespread, resulting from the perceived lack of support from the government, media and the general public at a time of staff shortages and high workload. Trends in themes were apparent, with emphasis on PPE, testing and safety March to May 2020 and morale, abuse, closed GP surgeries, testing, flu vaccines and overworked September to October 2020. From December 2020 the COVID-19 vaccine dominated posts. ConclusionGPs experiences and perceptions as reflected in their social media posts during the pandemic have changed over time; perceived lack of support and resources, and negative public perceptions have exacerbated their concerns about existing underlying pressures.

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

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

BackgroundThere has been scant evidence about the safety and efficacy of Physician Associates (PA) working within primary care. The recent climate created by qualitative surveys have not been helpful in understanding the use of dependent practitioners within the primary care setting. AimThis study aimed to compare outcomes in terms of safety of same-day requested consultations of differentiated and undifferentiated patients by PAs, Advanced Nurse practitioners (ANP) and post graduate doctors in training (PGDiT) within a large academic general practice. Design and settingAn observational study of 4979 patient records presenting at same-day appointments at a large general practice in Leicestershire over a 6-month period between June -December 2024. MethodPA consultations were compared with those ANPs and PGDiT. These were sub-divided into differentiated and undifferentiated patient presentations. Primary outcome was re-consultation within 14 days for the same or linked problem. Secondary outcomes were processes of care. ResultsThere were no significant differences in the rates of re-consultation (rate ratio 1.35, 95% confidence interval [CI] = 0.76 to 1.89, P = 0.29) in both groups of patients. There were no differences in rates of diagnostic tests ordered (1.14, 95% CI = 0.89 to 1.30, P = 0.74), referrals (0.91, 95% CI = 0.69 to 1.63, P = 0.87), prescriptions issued (1.26, 95% CI = 0.77 to 1.43, P = 0.39) in either of the patient cohorts examined. However, patient satisfaction rates were higher within the ANP group than the other two groups (0.86, 95% CI = 0.42 to 2.36, p<0.001). Records of initial consultations of 79.2% (n = 596) of PAs; 48.3% (n = 399) of ANP and 78.5% of PGDiTs were judged appropriate by Principal GPs at the practice (P<0.001). There was no difference in rates of referrals onto secondary care (rate ratio 1.24, 95%CI= 0.67 to 1.77; P=0.76) between the groups for either patient cohorts. PGDiTs did have a higher utilization of imaging resources when compared to the other two groups (RR 1.78 95% CI= 1.01 to 2.8; p<0.001). ConclusionThe processes and outcomes of PA and other dependent practitioner consultations for same-day appointment patients are similar and appear to be safe within primary care for all patient types. PAs offer an acceptable and efficient addition to the general practice workforce.

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 [&ge;]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

BackgroundThere is limited data on system-level factors associated with equitable access to high-quality primary care. We examine whether individual-level socioeconomic variation in general practitioner (GP) quality-of-care varies by area-level organisation of primary healthcare (PHC) services. MethodsBaseline data (2006-2009) from the Sax Institutes 45 and Up Study, involving 267,153 adults in New South Wales, Australia, were linked to Medicare Benefits Schedule and death data (to December 2012). Using multilevel logistic regression with cross-level interaction terms we quantified the relationship between small area-level PHC service characteristics and individual-level socioeconomic variation in need-adjusted quality-of-care (continuity-of-care, long-consultations, and care planning), separately by remoteness. Key findingsIn major cities, more bulk-billing(i.e. no co-payment) and chronic disease services and fewer out-of-pocket costs within areas were associated with an increased odds of continuity-of-care--more so among people of high-than low-education (e.g. bulk-billing interaction with university versus no school certificate 1.006[1.000,1.011]). While more bulk-billing, after-hours services and fewer OPC were associated with long-consultations and care planning across all education levels, in regional locations alone, more after-hours services were associated with larger increases in the odds of long consultations among people with low-than high-education (0.970[0.951,0.989]). Area GP availability was not associated with outcomes. ImplicationsIn major cities, PHC initiatives at the local level, such as bulk-billing and after-hours access, were not associated with a relative benefit for low-compared to high-education individuals. In regional locations, policies supporting after-hour access may improve access to long consultations, more so for people with low-compared to high-education. Key messagesO_ST_ABSWhat we knowC_ST_ABSO_LIEquitable access to high-quality primary healthcare is expected to reduce socioeconomic inequalities in health. C_LIO_LIQuality-of-care varies according to both individual socioeconomic position and local primary healthcare service organisation and delivery. C_LIO_LIHowever, there is limited data on system-level factors associated with equitable access to high-quality care. C_LI What this study addsO_LIIn major cities, area-level primary healthcare service characteristics such as bulk-billing (i.e. no co-payment), out-of-pocket costs, chronic disease and after-hours services were not associated with a relative benefit for low-education individuals compared with high-education in quality-of-care. C_LIO_LIIn regional areas, more after-hours services were associated with a higher likelihood of long consultations - more so for people of low-education than high-education. C_LI How this study might affect research, practice or policyO_LIThe identified area-level service characteristics associated with socioeconomic variation in care indicate avenues for providers and policy makers for improving healthcare equity. C_LIO_LIImproved data measuring area-level primary healthcare service organisation is needed to better measure the impact of policy initiatives. C_LI