Primary Care In England Research Articles

Advancing care in type 2 diabetes and atherosclerosis: assessing pharmacist-led strategies in England's primary care - a retrospective observational study

Abstract Background Type 2 diabetes (T2D) mellitus is a complex multi-system disorder with a tendency to develop complications. ‘Persistence to therapy’ plans affect almost 50% of all people with T2D, leading to suboptimal glycaemic and cardiovascular (CVD) risk factor control. The interplay between T2D and established atherosclerotic cardiovascular disease (ASCVD) underscores the need for a comprehensive, multidisciplinary approach to care that addresses both glycaemic control and CVD risk factors. Purpose This study retrospectively analysed pharmacist-led interventions in patients living with T2D and established ASCVD in general practices in a large UK city. Methods A retrospective pre-post observational study was conducted using electronic health record data from men and women diagnosed with T2D and ASCVD. Participants attended an independent prescribing pharmacist-led clinic within 21 general practices. The practices operated linked and comprehensive electronic health records systems, facilitating access to high-quality longitudinal data that align with study objectives. Results A total of 380 patients received pharmacist-led interventions. Comparisons of pre-intervention and post-intervention data revealed a significant decrease in HbA1c levels (73.7 ± 10.7 mmol/mol vs 67.2 ± 8.5 mmol/mol, p < 0.01), systolic blood pressure (132 ± 10.2 mmHg vs 125.9 ± 9.9 mmHg, p < 0.01), and diastolic blood pressure (76.8 ± 5.9 mmHg vs 72.4 ± 5.0 mmHg, p < 0.001). Additionally, total cholesterol levels significantly reduced from 4.4 ± 0.7 mmol/L to 3.9 ± 0.7 mmol/L (p < 0.001). The proportion of patients achieving the triple target of HbA1c (≤58 mmol/mol), BP (≤140/80 mmHg), and total cholesterol (≤5 mmol/L) increased significantly from 2.4% before the intervention to 23.4% afterward (p < 0.001). The initiation of the sodium-glucose co-transporter 2 inhibitors (SGLT2i) therapies was the most common prescribing intervention (67%). Conclusions Pharmacist-led interventions in a general practice setting significantly improved several critical diabetes and CVD risk related outcomes. These findings underscore the potential benefits of integrating pharmacist-led care models into the management of T2D, particularly for patients with concurrent ASCVD and adopting an individualised, evidence-based approach to prescribing interventions.

Factors affecting prostate cancer detection through asymptomatic PSA testing in primary care in England: Evidence from the 2018 National Cancer Diagnosis Audit.

Background Prostate-Specific Antigen (PSA) is used in primary care for prostate cancer detection, either for symptomatic assessment or asymptomatic testing following an informed decision. Aim To estimate the proportion of prostate cancer cases diagnosed following asymptomatic PSA testing, and patient and practice factors influencing this route. Design and setting 2018 English National Cancer Diagnosis Audit (NCDA) data were analysed, with linkage to the national cancer registry, practice-level Quality Outcomes Framework (QOF), and General Practice Patient Survey (GPPS) data. All 2018 NCDA patients with a diagnosis of prostate cancer were included (n = 9,837). Method Patients with recorded biomarker testing and no recorded symptoms prior to diagnosis were classified as asymptomatic PSA detected prostate cancer. Patient (age, ethnicity, deprivation, co-morbidities) and GP practice (geographical location, area deprivation, list size, urgent suspected cancer referral rate, QOF outcomes, GPPS results) factors were analysed for association with asymptomatic PSA testing using mixed effects logistic regression models. Results 1,884 out of 9,837 (19%) prostate cancer cases were detected following asymptomatic PSA testing, 982 (52.1%) of whom were patients aged 50-69 years. Younger age, non-White ethnicity, lower deprivation, and lower co-morbidity count were associated with an increased likelihood of diagnosis following asymptomatic PSA testing. There was a 13-fold variation between practices in the odds of asymptomatic PSA-detected cases, without clear explanatory GP practice-level factors. Conclusion One in five patients with prostate cancer in England are diagnosed after asymptomatic PSA testing in primary care, with large variation in asymptomatic PSA detection between GP practices.

Primary care experiences of adults reporting learning disability: a probability sample survey.

Background Adults with learning disability face multiple adversities, but evidence on their needs and primary care experiences is limited. Aim To compare the characteristics and primary care experiences of adults reporting learning disability with those who did not. Design and setting An analysis of the 2022 General Practice Patient Survey, a national probability sample survey conducted in 2022 with people registered with NHS primary care in England. Method This analysis reports descriptive profiles, weighted and with 95% confidence intervals. Logistic regression models adjusting for gender, age, ethnicity, and area-level deprivation compared experiences of adults reporting learning disability with those who did not. Results Survey participants comprised 623,157 people aged 16 or older, including 6,711 reporting learning disability. Adults reporting learning disability were more likely to be male, younger, of mixed or multiple ethnicities, and live in more deprived areas. All chronic conditions included in the survey were more common in adults reporting learning disability, especially reported sensory, neurodevelopmental, neurological, and mental health conditions. Adults reporting learning disability were twice as likely to have a preferred GP, and less likely to find their practice's website easy to navigate. They were also less likely to have confidence and trust in their healthcare professional, or feel their needs were met. Conclusion Adults reporting a learning disability had a higher likelihood of chronic health conditions. Their reported experiences of primary care indicate that despite recent initiatives to improve services offered, further adaptations to the consistency and ease of access to primary care is needed.

Experiences of integrating social prescribing link workers into primary care in England: Bolting on, fitting in or belonging.

Following the 2019 NHS Long-Term Plan, link workers (LWs) have been employed across primary care in England to deliver social prescribing (SP). To understand and explain how the LW role is being implemented in primary care in England. Realist evaluation undertaken in England. Focused ethnographies around seven LWs from different parts of England. As part of this, we interviewed 61 patients and 93 professionals from healthcare and the voluntary, community and social enterprise (VCSE) sector. We reinterviewed 41 patients, seven LWs and a LW manager 9-12 months after their first interview. We developed four concepts around how LWs are integrated (or not) within primary care: Centralising or diffusing power; Forging an identity in general practice; Demonstrating effect; Building a facilitative infrastructure. These concepts informed the development of a programme theory around a continuum of integration of LWs into primary care - from being 'bolted on' to existing provision, without much consideration, to 'fitting in', shaping what is delivered to be accommodating, through to 'belonging', whereby they are accepted as a legitimate source of support, making a valued contribution to patients' broader well-being. SP was introduced into primary care to promote greater attention to the full range of factors affecting patients' health and well-being, beyond biomedicine. For that to happen, our analysis highlights the need for a whole system approach to defining, delivering and maintaining this new part of practice.

The consequences of micro-discretions and boundaries in the social prescribing link worker role in England: a realist evaluation.

Social prescribing addresses non-medical factors affecting health and well-being. Link workers are key to its delivery by connecting people to relevant support, often in the voluntary, community and social enterprise sector. Funding from the National Health Service means that link workers are becoming a common part of primary care in England. To explore and understand the implementation of link workers in primary care in England. A realist evaluation addressed the question - When implementing link workers in primary care to sustain outcomes - what works, for whom, why and in what circumstances? Link workers and staff associated with seven primary care sites across England. Researchers spent 3 weeks with each link worker, going to meetings with them, watching them interact with patients, with healthcare staff and with voluntary, community and social enterprise organisations. In addition, interviews were conducted with 61 patients and 93 professionals (voluntary, community and social enterprise representatives and healthcare staff, including link workers). Follow-up interviews were conducted with 41 patients and with link workers 9-12 months later. Data were coded and developed into statements to identify how context around the link worker triggers mechanisms that lead to intended and unintended outcomes. We found that link workers exercise micro-discretions in their role - actions and advice-giving based on personal judgement of a situation, which may not always reflect explicit guidance or protocols. Our analysis highlighted that micro-discretions engender positive connections (with patients, healthcare staff, the voluntary, community and social enterprise sector) and promote buy-in to the link worker role in primary care. Micro-discretions supported delivery of person-centred care and enhanced job satisfaction. Data also highlighted that lack of boundaries could place link workers at risk of overstepping their remit. Our research focused on link workers attached to primary care; findings may not be applicable to those working in other settings. Data were collected around seven link worker cases, who were selected purposively for variation in terms of geographical spread and how/by whom link workers were employed. However, these link workers were predominately white females. Enabling link workers to exercise micro-discretions allows for responsiveness to individual patient needs but can result in uncertainty and to link workers feeling overstretched. Poor link worker retention may, in part, be associated with a lack of clarity around their role. Research to explore how this shapes intention to leave their job is being conducted by authors of this paper. This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130247.

Exploring How Patients Are Supported to Use Online Services in Primary Care in England Through "Digital Facilitation": Survey Study.

Health service policy in many jurisdictions is driving greater investment into digital primary care services. While some patients and practices may benefit, there are concerns that not all are able or wish to access primary care services online. "Digital facilitation" is the "range of processes, procedures, and personnel seeking to support patients in their uptake and use of online services" and may address such concerns. As part of a multimethod research program, we undertook surveys of practice staff and patients to gain insight into the support being offered by practices and explore patients' experiences of this support. General practices from 4 regions of England were sent a questionnaire exploring the modes of digital facilitation offered, the personnel involved in its delivery, and views on the motivations and drivers for providing support. Moreover, 12,822 patients registered with 62 general practices (predominantly those providing practice survey responses) were sent a questionnaire exploring their experiences of any support offered by their practice to use online services. Almost one-third of practices (156/500, 31.2%) responded to the practice survey, with most reporting using passive modes of digital facilitation (eg, display, leaflets, and SMS text messages) and few using active modes (eg, offering tablets or computers or using practice champions). However, 90.9% (130/143) reported providing ad hoc support. Practices agreed that it was the responsibility of both the practice (105/144, 72.9%) and the wider National Health Service (118/143, 82.5%) to support patients in using online services and that providing such support benefited the practice (126/144, 87.5%) and their patients (132/144, 91.7%). Nearly a quarter of the patients (3051/12,822, 23.8%) responded to the patient survey, with few (522/3051, 17.11% or less) reporting awareness of any modes of digital facilitation apart from text messages and emails (1205/3051, 39.5%) and only 13.36% (392/2935) reporting receiving support to use online services. Adjusted logistic regression analyses showed that older patients had a lower likelihood of 4 outcomes: being aware of, or of using, digital facilitation efforts, or being told about or being helped to use online services (all P<.05), particularly with regard to being helped to use online services (adjusted odds ratio for patients aged 85 years versus those aged 55-64 years: 0.08, 95% CI 0.02-0.36). However, ethnic minority participants or those for whom their first language was not English had positive associations with these outcomes. General practices recognize that patients would benefit from support to access online services. However, the support provided is often passive or ad hoc, and patients were seldom aware of digital facilitation efforts that their practice provided. There is potential to increase engagement with online primary care services by providing more support for all patients, particularly to provide targeted support for older patients.

'Everyone has heard of it, but no one knows what it is': A qualitative study of patient understandings and experiences of herpes zoster.

Shingles (herpes zoster), caused by reactivation of the varicella-zoster virus, is usually diagnosed and managed in primary care. The lifetime risk of shingles in the general population is approximately 30%, and it can have a detrimental effect on quality of life. There has been little qualitative research about patient experience and understanding of shingles. Qualitative interviews with people recruited from primary care in England. Qualitative semi-structured remote interviews were undertaken with 29 participants in a randomised controlled trial in primary care in England (ATHENA, ISRCTN14490832). Participants were aged >49 and were diagnosed within six days of shingles rash onset. Interviewees were sampled for diversity in terms of pain, intervention adherence, age, gender, and ethnicity. Data were analysed using reflexive thematic analysis. Participants' understanding of shingles was limited, particularly pre-diagnosis. Television campaigns about the shingles vaccination programme helped some to recognise the rash. Shingles was understood as a disease with a variable prognosis, resulting in a sense of uncertainty about the significance when diagnosed. Participants reported a range of symptoms which impacted on everyday life. Some people thought their diagnosis was caused by poor mental health or challenging life circumstances, a perception sometimes reinforced by healthcare professionals. Many participants sought meaning in their diagnosis, reflecting upon, and sometimes changing, their life and circumstances. Primary care practitioners should be aware of the broad spectrum of patient knowledge, and the potential for better understanding to promote early attendance and treatment, to reduce the impact of shingles.

Evaluation of a Musculoskeletal Digital Assessment Routing Tool (DART): Crossover Noninferiority Randomized Pilot Trial.

Musculoskeletal conditions account for 16% of global disability, resulting in a negative effect on patients and increasing demand for health care use. Triage directing patients to appropriate level intervention improving health outcomes and efficiency has been prioritized. We developed a musculoskeletal digital assessment routing tool (DART) mobile health (mHealth) system, which requires evaluation prior to implementation. Such innovations are rarely rigorously tested in clinical trials-considered the gold standard for evaluating safety and efficacy. This pilot study is a precursor to a trial assessing DART performance with a physiotherapist-led triage assessment. The study aims to evaluate trial design, assess procedures, and collect exploratory data to establish the feasibility of delivering an adequately powered, definitive randomized trial, assessing DART safety and efficacy in an NHS primary care setting. A crossover, noninferiority pilot trial using an integrated knowledge translation approach within a National Health Service England primary care setting. Participants were patients seeking assessment for a musculoskeletal condition, completing a DART assessment and the history-taking element of a face-to-face physiotherapist-led triage in a randomized order. The primary outcome was agreement between DART and physiotherapist triage recommendation. Data allowed analysis of participant recruitment and retention, randomization, blinding, study burden, and potential barriers to intervention delivery. Participant satisfaction was measured using the System Usability Scale. Over 8 weeks, 129 patients were invited to participate. Of these, 92% (119/129) proceeded to eligibility assessment, with 60% (78/129) meeting the inclusion criteria and being randomized into each intervention arm (39/39). There were no dropouts and data were analyzed for all 78 participants. Agreement between physiotherapist and DART across all participants and all primary triage outcomes was 41% (32/78; 95% CI 22-45), intraclass correlation coefficient 0.37 (95% CI 0.16-0.55), indicating that the reliability of DART was poor to moderate. Feedback from the clinical service team led to an adjusted analysis yielding of 78% (61/78; 95% CI 47-78) and an intraclass correlation coefficient of 0.57 (95% CI 0.40-0.70). Participant satisfaction was measured quantitively using amalgamated System Usability Scale scores (n=78; mean score 84.0; 90% CI +2.94 to -2.94), equating to an "excellent" system. There were no study incidents, and the trial burden was acceptable. Physiotherapist-DART agreement of 78%, with no adverse triage decisions and high patient satisfaction, was sufficient to conclude DART had the potential to improve the musculoskeletal pathway. Study validity was enhanced by the recruitment of real-world patients and using an integrated knowledge translation approach. Completion of a context-specific consensus process is recommended to provide definitive definitions of safety criteria, range of appropriateness, noninferiority margin, and sample size. This pilot demonstrated an adequately powered definitive trial is feasible, which would provide evidence of DART safety and efficacy, ultimately informing potential for DART implementation. ClinicalTrials.gov NCT04904029; http://clinicaltrials.gov/ct2/show/NCT04904029. RR2-10.2196/31541.

A Multi-dimensional Framework of Valued Output for Primary Care in England.

Improving efficiency and productivity are key aspects to ensure that general practices in England can meet the needs of a growing population with increasingly demanding and costly healthcare needs. However, current evidence on the efficiency and productivity of general practices is weak, partly due to suboptimal approaches to measure their 'valued' output. To overcome this limitation, this paper presents a multi-dimensional framework and indicators of valued output from the healthcare decision-maker's perspective. We identified existing primary care performance frameworks through a targeted literature review. We reviewed the frameworks and selected the dimensions relating to the impact on patients' health outcomes, corresponding with the definition of 'valued' output from the healthcare decision-maker perspective. For each dimension, we reviewed the National Institute for Health and Care Excellence (NICE) evidence base and guidance on best practice to develop indicators of valued output. Clinical experts and representatives of the main primary care stakeholders reviewed and validated the framework's comprehensiveness and development process. Based on a review of three existing frameworks, we synthesised a multi-dimensional output framework comprising 13 dimensions for significant primary care-related conditions and services and 51 indicators of valued output. Each indicator of valued output measures a healthcare episode and the resulting impact on patient's health. The multi-dimensional framework and indicators provide a theoretical tool to improve the measurement of primary care output in economic efficiency and productivity studies. Future research should explore the measurability of the indicators through available datasets and the implementation of the framework through analytical approaches for efficiency measurement.

Pilot postal birth cohort HCV Screening in UK primary care.

Birth cohort screening has been implemented in some countries to identify the potentially 'missed population' of undiagnosed chronic Hepatitis C Virus (HCV) in people who may not be found through targeted approaches. To determine uptake of HCV antibody testing using an oral swab screening method, overall yield, whether those testing positive had risk markers in their primary care record, and cost per case detected. Pilot screening study set in general practices in the Southwest, South London and Yorkshire and Humber. Participants consenting were sent an oral swab kit in the post and saliva samples were tested for antibody to HCV. 16,436/98,396 (16.7%) patients consented and were sent an oral swab kit. 12,216 (12.4%) returned a kit, with 31 participants (yield 0.03%) testing positive for HCV antibody. 45% of those positive had a risk marker for HCV on their primary care record. Two (yield 0.002%) were confirmed RNA positive and referred for treatment, both had HCV risk markers. Cost per case detected was £16,000 per HCV antibody and £247,997 per chronic HCV. Wide-scale screening could be delivered and identified people infected with HCV, however most of these individuals could have been detected through lower-cost targeted screening. Yield and cost per case found were substantially worse than model estimates and targeted screening studies. Birth cohort screening should not be rolled out in primary care in England.

Impact of COVID-19 pandemic on the utilization and quality of antibiotic use in the primary care setting in England, March 2019–March 2023: a segmented interrupted time series analysis of over 53 million individuals

ABSTRACT Background Amid the COVID-19 pandemic, we evaluated the short-term impact of COVID-19 on antibiotic use in primary care in England, focusing on both antibiotic quantity (overuse) and quality (misuse) of use. Research design and methods A population-based segmented interrupted analysis was applied on monthly dispensed antibiotics prescriptions using the Prescription Cost Analysis dataset (March/2019–March/2023). The quantity was assessed using number of items dispensed per 1000 inhabitants (NTI) and defined daily doses per 1000 inhabitants per day (DID), while quality was evaluated using WHO’s Access Watch Reserve (AWaRe) classification, the proportion of ‘4C’ antibiotics and the percentage of broad- to narrow-spectrum antibiotics. Results Findings indicate 8.6 (17.2%) and 0.4 (2.6%) increase in the NTI and DID, respectively, with a statistically significant uptick in trend noted after the second lockdown (β5) for ‘total antibiotics’ for NTI only (β5 = 1.6; 95% CI:0.17, 3.1). Quality assessment showed an increase in ‘Access’ antibiotics from 77% in March/2019 to 86% in March/2023; however, COVID-19 had no significant impact on WHO AWaRe classes. Conclusion COVID-19’s impact on antibiotic use quality and quantity appeared to be minimal, though an increase in utilization post-second lockdown coincided with healthcare system recovery. This suggests a nuanced impact of the pandemic, highlighting the importance of continued antimicrobial stewardship.

Identifying multi-resolution clusters of diseases in ten million patients with multimorbidity in primary care in England

BackgroundIdentifying clusters of diseases may aid understanding of shared aetiology, management of co-morbidities, and the discovery of new disease associations. Our study aims to identify disease clusters using a large set of long-term conditions and comparing methods that use the co-occurrence of diseases versus methods that use the sequence of disease development in a person over time.MethodsWe use electronic health records from over ten million people with multimorbidity registered to primary care in England. First, we extract data-driven representations of 212 diseases from patient records employing (i) co-occurrence-based methods and (ii) sequence-based natural language processing methods. Second, we apply the graph-based Markov Multiscale Community Detection (MMCD) to identify clusters based on disease similarity at multiple resolutions. We evaluate the representations and clusters using a clinically curated set of 253 known disease association pairs, and qualitatively assess the interpretability of the clusters.ResultsBoth co-occurrence and sequence-based algorithms generate interpretable disease representations, with the best performance from the skip-gram algorithm. MMCD outperforms k-means and hierarchical clustering in explaining known disease associations. We find that diseases display an almost-hierarchical structure across resolutions from closely to more loosely similar co-occurrence patterns and identify interpretable clusters corresponding to both established and novel patterns.ConclusionsOur method provides a tool for clustering diseases at different levels of resolution from co-occurrence patterns in high-dimensional electronic health records, which could be used to facilitate discovery of associations between diseases in the future.

Ethnic inequities in 6-8 week baby check coverage in England 2006- 2021: a cohort study using the Clinical Practice Research Datalink.

Inequities in the coverage of 6-8-week maternal checks, health visitor reviews, and infant vaccinations have been reported in England. Ethnic inequities in 6-8-week baby checks have not been studied nationally. To examine the effect of maternal ethnicity on 6-8 week baby check coverage in England 2006-2021. This cohort study used electronic health records from primary care in England. Baby check coverage was calculated in 16 ethnic groups, by year and region. Risk ratios were estimated using modified Poisson regression. Coverage and timing of baby checks in relation to maternal checks and infant vaccinations by ethnic group were calculated. Ethnic inequities in 6-8 week baby check coverage in England varied by year and region. Coverage increased 2006-2007 to 2015-2016, then stabilised to 80-90% for most groups. Coverage was lowest for Bangladeshi and Pakistani groups 2006-2007 to 2011-2012. In the West Midlands, coverage was lowest at approximately 60% for four groups: Bangladeshi, Caribbean, African, and Any other Black, African or Caribbean background. In the North West, coverage was lowest for Bangladeshi (65.3%) and Pakistani (69.2%) groups. These patterns remained after adjusting for other factors and persisted over time. Coverage was highest in those whose mothers received a maternal check and those who received at least one dose of 8-week infant vaccinations. Coordinated action at the level of integrated commissioning boards, primary care networks, and GP practices is required to better understand the reasons behind these inequities and redress the persistent disparities in 6-8 week baby check coverage.

Phenotype-based targeted treatment of SGLT2 inhibitors and GLP-1 receptor agonists in type 2 diabetes

Aims/hypothesisA precision medicine approach in type 2 diabetes could enhance targeting specific glucose-lowering therapies to individual patients most likely to benefit. We aimed to use the recently developed Bayesian causal forest (BCF) method to develop and validate an individualised treatment selection algorithm for two major type 2 diabetes drug classes, sodium–glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA).MethodsWe designed a predictive algorithm using BCF to estimate individual-level conditional average treatment effects for 12-month glycaemic outcome (HbA1c) between SGLT2i and GLP1-RA, based on routine clinical features of 46,394 people with type 2 diabetes in primary care in England (Clinical Practice Research Datalink; 27,319 for model development, 19,075 for hold-out validation), with additional external validation in 2252 people with type 2 diabetes from Scotland (SCI-Diabetes [Tayside & Fife]). Differences in glycaemic outcome with GLP1-RA by sex seen in clinical data were replicated in clinical trial data (HARMONY programme: liraglutide [n=389] and albiglutide [n=1682]). As secondary outcomes, we evaluated the impacts of targeting therapy based on glycaemic response on weight change, tolerability and longer-term risk of new-onset microvascular complications, macrovascular complications and adverse kidney events.ResultsModel development identified marked heterogeneity in glycaemic response, with 4787 (17.5%) of the development cohort having a predicted HbA1c benefit >3 mmol/mol (>0.3%) with SGLT2i over GLP1-RA and 5551 (20.3%) having a predicted HbA1c benefit >3 mmol/mol with GLP1-RA over SGLT2i. Calibration was good in hold-back validation, and external validation in an independent Scottish dataset identified clear differences in glycaemic outcomes between those predicted to benefit from each therapy. Sex, with women markedly more responsive to GLP1-RA, was identified as a major treatment effect modifier in both the UK observational datasets and in clinical trial data: HARMONY-7 liraglutide (GLP1-RA): 4.4 mmol/mol (95% credible interval [95% CrI] 2.2, 6.3) (0.4% [95% CrI 0.2, 0.6]) greater response in women than men. Targeting the two therapies based on predicted glycaemic response was also associated with improvements in short-term tolerability and long-term risk of new-onset microvascular complications.Conclusions/interpretationPrecision medicine approaches can facilitate effective individualised treatment choice between SGLT2i and GLP1-RA therapies, and the use of routinely collected clinical features for treatment selection could support low-cost deployment in many countries.Graphical

Ethnicity data resource in population-wide health records: completeness, coverage and granularity of diversity

Intersectional social determinants including ethnicity are vital in health research. We curated a population-wide data resource of self-identified ethnicity data from over 60 million individuals in England primary care, linking it to hospital records. We assessed ethnicity data in terms of completeness, consistency, and granularity and found one in ten individuals do not have ethnicity information recorded in primary care. By linking to hospital records, ethnicity data were completed for 94% of individuals. By reconciling SNOMED-CT concepts and census-level categories into a consistent hierarchy, we organised more than 250 ethnicity sub-groups including and beyond “White”, “Black”, “Asian”, “Mixed” and “Other, and found them to be distributed in proportions similar to the general population. This large observational dataset presents an algorithmic hierarchy to represent self-identified ethnicity data collected across heterogeneous healthcare settings. Accurate and easily accessible ethnicity data can lead to a better understanding of population diversity, which is important to address disparities and influence policy recommendations that can translate into better, fairer health for all.

Assessing the uptake of incentivised physical health checks for people with serious mental illness: a cohort study in primary care.

People with serious mental illness are more likely to experience physical illnesses. The onset of many of these illnesses can be prevented if detected early. Physical health screening for people with serious mental illness is incentivised in primary care in England through the Quality and Outcomes Framework (QOF). GPs are paid to conduct annual physical health checks on patients with serious mental illness, including checks of body mass index (BMI), cholesterol, and alcohol consumption. To assess the impact of removing and reintroducing QOF financial incentives on uptake of three physical health checks (BMI, cholesterol, and alcohol consumption) for patients with serious mental illness. Cohort study using UK primary care data from the Clinical Practice Research Datalink between April 2011 and March 2020. A difference-in-difference analysis was employed to compare differences in the uptake of physical health checks before and after the intervention, accounting for relevant observed and unobserved confounders. An immediate change was found in uptake after physical health checks were removed from, and after they were added back to, the QOF list. For BMI, cholesterol, and alcohol checks, the overall impact of removal was a reduction in uptake of 14.3, 6.8, and 11.9 percentage points, respectively. The reintroduction of BMI screening in the QOF increased the uptake by 10.2 percentage points. This analysis supports the hypothesis that QOF incentives lead to better uptake of physical health checks.

Primary care provision for young people with ADHD: a multi-perspective qualitative study.

Attention deficit hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder. UK guidance states that primary care has a vital role in effective ADHD management, including referral, medication prescribing and monitoring, and providing broader mental health and wellbeing support. However, many GPs feel unsupported to provide health care for young people with ADHD. Inadequate health care is associated with rising costs for patients and society. To investigate the experiences of young people with ADHD accessing primary care in England, from the perspectives of people with lived experience of ADHD and healthcare professionals (HCPs). A qualitative study. Interviews were conducted with HCPs (GPs, practice managers, and a wellbeing worker) and people with lived experience of ADHD (young people aged 16-25 years and their supporters) located in integrated care systems across England. Semi-structured interviews were conducted with participants at five purposively selected general practices (varying by deprivation, ethnicity, and setting). Questions focused on experiences of accessing/providing health care for ADHD. Reflexive thematic analysis was undertaken within a critical realist framework to understand how provision works in practice and to explore potential improvements. In total, 20 interviews were completed with 11 HCPs and nine people with lived experience. Three themes were generated: a system under stress, incompatibility between ADHD and the healthcare system, and strategies for change in ADHD primary care provision. Standardisation of ADHD management in primary care, providing better information and support for HCPs, and advising on reasonable adjustments for people with lived experience could help improve access to effective treatments for young people living with ADHD.

Appraisal of National Institute for Health and Care Research activity in primary care in England: cross-sectional study.

The National Institute for Health and Care Research (NIHR) was set up to enhance clinical and health research activity in a variety of National Health Service (NHS) healthcare settings, including primary care. To appraise how overall General Practitioner (GP) practice performance, location, and staffing levels may interact with NIHR Portfolio activity in primary care in England. Cross-sectional summary of GP practice research activity and practice descriptors; complete data from 6,171 GP practices was collated from NIHR (using data for 2013-2023 for Portfolio studies), Public Health England, Care Quality Commission, and NHS Digital sources, respectively. In primary care, 1 million patients have been recruited into NIHR Portfolio studies in the last decade. The top 10% of practices-measured by different studies recruited to-contributed over 50% of that accrual. When the top decile of GP practices is compared to the 20% least active GP practices, research activity is significantly and individually linked with larger GP practices. Furthermore, it is significantly yet modestly associated with GP practice performance (positive patient feedback, Care Quality Commission rating), lower locality deprivation levels, and lower patient to GP ratios. Research activity in GP practices is-as seen previously with hospitals-significantly linked with better GP practice performance and patient feedback. Practice list size and staffing levels in particular interact with the aforementioned. This should be taken into account when determining strategies to increase patient and GP practice participation in NIHR Portfolio research studies.

Does workforce explain the relationship between funding and patient experience? A mediation analysis of primary care data in England

ObjectivesTo determine whether general practitioner (GP) workforce contributes to the link between practice funding and patient experience. Specifically, to determine whether increased practice funding is associated with better patient experience,...

Exploring the experiences and preferences of South Asian patients' of primary care in England since COVID-19.

Remote (digital and/or telephone) access and consultation models are being driven by national policy with the goal being that the National Health Service operateon a remote-first (digital-first) basis by 2029. Previous research has suggested that remote methods of access to care and consulting may act to widen health inequalities for certain patients and/or groups such as those from ethnic minorities. South Asian (SA) patients comprise the largest ethnic minority group in England. Understanding the experiences and needs of this group is critical to ensuring that general practice can deliver equitable, quality health care. Qualitative study. 37 participants (from Indian, Pakistani and/or Bangladeshi background) were recruited to take part in either in-person preferred language focus groups or remote semistructured interviews in the English language. Thematic analysis was conducted to identify themes in the qualitative data. Three major interlinked themes were identified: (1) reduced access, (2) reduced patient choiceand (3) quality and safety concerns. The findings highlight access issues split by (i) general issues with appointment access via any remote means and (ii) specific issues related to language barriers creating additional barriers to access and care. Some patients valued the convenience of remote access but also raised concerns regarding appointment availability and reduced patient choice. Face-to-face consultations were preferable but less available. The findings underscore how participants perceived remote care to be of lesser quality and less safe. Concerns were greatest for those with limited English proficiency (LEP), with the removal of non-verbal aspects of communication and 'hands-on' care leading to perceptions of reduced psycho-social safety. SA patients' experiences of remote-led primary care access and care delivery were negative with only a minority viewing it positively and for certain limited scenarios. Face-to-face models of care remain the preferred mode of consultation, particularly for those with LEP. Hybrid models of access offer patients the greatest choice, and are likely to meet the varying needs of the South-Asian patient population going forwards. The remote first approach to primary care may be achievable as a service ideal, but its limitations need to be recognised and accounted for to ensure that primary care can be an equitable service, both now and in the future. Members of the public were involved in all phases of research in the study. This included co-working in partnership throughout the study including, reviewing patient-facing documents, recruiting participants, data facilitation, translation work, interpretation of the data and co-authors on this manuscript. The key to the success of our study was collaborative teamwork, which involved experienced members of the public with SA cultural knowledge working together with and integral to the research team for all components.