Royal College Of General Practitioners Research Articles

Management of unscheduled bleeding on HRT: A joint guideline on behalf of the British Menopause Society, Royal College Obstetricians and Gynaecologists, British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Faculty of Sexual and Reproductive Health, Royal College of General Practitioners and Getting it Right First Time.

Unscheduled bleeding on hormone replacement therapy (HRT) can affect up to 40% of users. In parallel with the increase in HRT prescribing in the UK, there has been an associated increase in referrals to the urgent suspicion of cancer pathway for unscheduled bleeding. On behalf of the British Menopause Society (BMS) an expert review panel was established, including primary and secondary care clinicians with expertise in the management of menopause, with representatives from key related organisations, including the Royal College of Obstetricians & Gynaecologists, the British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Royal College of General Practitioners and Faculty of Sexual and Reproductive Health, and service development partners from NHS England and GIRFT (Getting it Right First Time). For each topic, a focused literature review was completed to develop evidence led recommendations, where available, which were ratified by consensus review within the panel and by guideline groups.

A movement for movement: an exploratory study of primary healthcare professionals' perspectives on implementing the Royal College of General Practitioners' active practice charter initiative.

Regular physical activity (PA) results in extensive physical, psychological, and social benefits. Despite primary care being a key point of influence for PA behaviours in the UK, research indicates poor application of PA interventions in this context. To address this, the Royal College of General Practitioners' (RCGP) developed and implemented the Active Practice Charter (APC). The aim of the study was to evaluate the perceived impact and acceptability of the APC initiative from the perspective of primary healthcare professionals (PHPs). An online exploratory cross-sectional survey was designed to assess the perceived impact, experiences, and challenges of the APC initiative, from the perspective of PHPs. The survey was distributed by the RCGP via email to 184 registered APC practices across the UK. Responses were reviewed from staff (n = 33) from 21 APC practices. Initiatives used by APC practices included: educational programmes, partnerships with PA providers, referral systems, and infrastructure investment. Perceived benefits included: increased awareness about PA, staff cohesion, and improved well-being. However, staff felt the APC had limited effect due to implementation barriers, including: a lack of engagement, time, resources, and funding. This is the first evaluation of any nationwide UK-based initiative engaging GP practices in promoting PA. Acknowledging the limitations in response rate, although support exists for the RCGP APC, the evaluation highlights challenges to its implementation. Nonetheless, the wide reach of the RCGP, combined with the cited staff and patient benefits, demonstrates the significant potential of the APC initiative. Given the need to address physical inactivity nationally, further development the APC offers a possible solution, with further research required to overcome the challenges to implementation.

The Adhesive Capsulitis Corticosteroid and Dilation (ACCorD) randomized controlled trial.

Is it feasible to conduct a definitive multicentre trial in community settings of corticosteroid injections (CSI) and hydrodilation (HD) compared to CSI for patients with frozen shoulder? An adequately powered definitive randomized controlled trial (RCT) delivered in primary care will inform clinicians and the public whether hydrodilation is a clinically and cost-effective intervention. In this study, prior to a full RCT, we propose a feasibility trial to evaluate recruitment and retention by patient and clinician willingness of randomization; rates of withdrawal, crossover and attrition; and feasibility of outcome data collection from routine primary and secondary care data. In the UK, the National Institute for Health and Care Excellence (NICE) advises that prompt early management of frozen shoulder is initiated in primary care settings with analgesia, physiotherapy, and joint injections; most people can be managed without an operation. Currently, there is variation in the type of joint injection: 1) CSI, thought to reduce the inflammation of the capsule reducing pain; and 2) HD, where a small volume of fluid is injected into the shoulder joint along with the steroid, aiming to stretch the capsule of the shoulder to improve pain, but also allowing greater movement. The creation of musculoskeletal hubs nationwide provides infrastructure for the early and effective management of frozen shoulder. This potentially reduces costs to individuals and the wider NHS perhaps negating the need for a secondary care referral. We will conduct a multicentre RCT comparing CSI and HD in combination with CSI alone. Patients aged 18 years and over with a clinical diagnosis of frozen shoulder will be randomized and blinded to receive either CSI and HD in combination, or CSI alone. Feasibility outcomes include the rate of randomization as a proportion of eligible patients and the ability to use routinely collected data for outcome evaluation. This study has involved patients and the public in the trial design, dissemination methods, and how to include groups who are underserved by research. We will disseminate findings among musculoskeletal clinicians via the British Orthopaedic Association, the Chartered Society of Physiotherapy, the Royal College of Radiologists, and the Royal College of General Practitioners. To ensure wide reach we will communicate findings through our established network of charities and organizations, in addition to preparing dissemination findings in Bangla and Urdu (commonly spoken languages in northeast London). If a full trial is shown to be feasible, we will seek additional National Institute for Health and Care Research funding for a definitive RCT. This definitive study will inform NICE guidelines for the management of frozen shoulder.

New evidence on the validity of the selection methods for recruitment to general practice training: a cohort study.

Selection into UK-based GP training has used the Multi-Specialty Recruitment Assessment (MSRA) and a face-to-face selection centre (SC). The MSRA comprises of a situational judgement test and clinical problem-solving test. The SC was suspended during the COVID-19 pandemic. Evidence is needed to guide national and international selection policy. To evaluate the validity of GP training selection. A retrospective cohort study using data from UK-based national recruitment to GP training, from 2015-2021. Data were available for 32 215 GP training applicants. The ability of scores from the specialty selection process to predict subsequent performance in the Clinical Skills Assessment (CSA) of the Membership of the Royal College of General Practitioners examination was modelled using path analysis. The effect sizes for sex, professional family background, and world region of qualification were estimated. All component scores of the selection process demonstrated statistically significant independent relationships with CSA performance (P<0.001), thus establishing their predictive validity. All were sensitive to demographic factors. The SC scores had the weakest relationship with future CSA performance. However, for candidates with MSRA scores below the lowest quartile, the relative contribution of the SC scores to predicting CSA performance was similar to that observed for MSRA components. The MSRA has predictive validity in this context. Re-instituting an SC for those with relatively low MSRA scores should be considered. However, the relative costs and potential advantages and disadvantages should be carefully weighed.

A national training course for clinical trainers in family medicine.

Quality vocational training is important to ensure that family physicians can strengthen the district health system. Competent clinical trainers and supervisors, with the necessary educational knowledge and skills, are required for this job. In 2014, a formal Train the Clinical Trainer (TCT) course was introduced in South Africa as a collaborative effort between the Royal College of General Practitioners (RCGP) and the South African Academy of Family Physicians (SAAFPs). To make the training relevant, the course was aligned with the National Unit Standards for Family Medicine, as these defined the learning outcomes for registrars. The aim of the TCT course was to equip workplace-based clinical trainers with an essential set of educational skills, which could be further developed through mentoring and support. Accredited trainers present the face-to-face course yearly to two family physicians from each of the nine departments of family medicine in South Africa. The TCT course is built around the educational principles of learner-centredness and andragogy. During these 5 days of training the roles and responsibilities of trainers and learners, the learning environment, alignment with the curriculum, assessment for and of learning, and leadership are covered. Recently online assessment, the e-portfolio and the use of entrustable professional activities were added to the course content. In the future we would like to accredit more clinical trainers through a process of workplace-based self-evaluation and 360-degree feedback from peers and students. Lastly, we want to expand the training course in the African region.Contribution: The Train the Clinical Trainer (TCT) course, established in 2014 through RCGP and SAAFP collaboration in South Africa, ensures family physicians have essential educational skills. Aligned with national standards, the course embraces learner-centered principles. Ongoing enhancements include online assessments and future plans involve accrediting more trainers through self-evaluation and expanding across the African region.

Performance of Generative Pre-trained Transformer-4 (GPT-4) in Membership of the Royal College of General Practitioners (MRCGP)-style examination questions.

Performance of Generative Pre-trained Transformer-4 (GPT-4) in Membership of the Royal College of General Practitioners (MRCGP)-style examination questions.

Urban green and blue spaces for influencing physical activity in the United Kingdom: A narrative review of the policy and evidence

AbstractIntroductionWith the rapid growth of urbanization globally and in the UK, increasing attention is now being directed towards urban green spaces (UGS). The appeal of UGS to policymakers lies in their capacity to address multiple policy objectives, including improving physical and mental wellbeing, mitigating noncommunicable diseases (NCDs), combating climate change through carbon sequestration, providing climate adaptation measures, and enhancing biodiversity.MethodThis narrative review gives an overview of the current literature and UK policy relating to urban green and blue spaces, with a particular focus on the use of UGS to increase physical activity levels.ResultsUGS have a profound impact on public health, with evidence indicating their positive effect on both physical and psychological health. Thirty‐eight percent of adults in the UK do not live within 15 minutes of UGS, so policy makers at national and international level are aiming to address this gap. One reason for the health benefits of UGS is associated increased physical activity, a vital component needed to address the burden of non‐communicable disease. To effectively harness UGS to promote physical activity various factors must be considered; proximity and diversity of urban green spaces, and the presence of suitable infrastructure features. Tailoring UGS to meet the needs and preferences of different population demographics is essential, as is ensuring safety, and addressing barriers to access particularly for lower socio‐economic groups. The careful planning of UGS must avoid potential gentrification effects and displacement of vulnerable communities, whilst utilising the equigenic nature of UGS.ConclusionsTo create a brighter future and capitalize on the potential of UGS, a collaborative approach is needed, involving communities, local governments, and national authorities. Primary‐care professionals, represented by organizations like the Royal College of General Practitioners (RCGP), can play a crucial role in advocating for UGS and physical activity, promoting their use, and providing guidance and support.

Burnout, psychological wellbeing, and musculoskeletal complaints in UK GPs: an observational study.

Healthcare systems are under unprecedented pressure. GPs are crucial to the health of the population, yet their own health and wellbeing is often overlooked. To investigate feelings of burnout, psychological wellbeing, and musculoskeletal complaints in GPs across the UK and to examine whether these health outcomes vary according to the time GPs spent sitting, their participation in physical activity each day, and the time spent working per day or week. Observational study involving GPs located across the UK. An online survey was emailed to working members of the Royal College of General Practitioners and shared on social media between October and December 2020. The survey included questions on burnout, psychological wellbeing, musculoskeletal complaints, sitting time, physical activity, and time spent working. Mean differences were examined for burnout, psychological wellbeing, and musculoskeletal complaints. Data from 406 GPs showed a high level of burnout (35.5%) and musculoskeletal complaints (neck, shoulder and back: 81.8%; arms: 28.3%; and legs: 49.8%). Psychological wellbeing was low in 22.9% of GPs. Burnout was lower in GPs who met current physical activity guidelines, while psychological wellbeing was higher in those with >2 breaks in sitting per hour. Musculoskeletal complaints were higher in those spending >50% of sitting time in prolonged bouts (≥30 minutes). A high proportion of GPs reported experiencing burnout and musculoskeletal complaints, but these health concerns were less evident in GPs who spent less time in prolonged sitting, took more breaks in sitting, and who were more physically active.

The challenges and experiences of providing end-of-life care in primary care: online survey and semi-structured interviews with UK primary care professionals.

Primary care professionals deliver the majority of end-of-life care to patients. However, extensive pressures and constraints can contribute to variable and substandard care quality. We will report on the preliminary results from an independent evaluation of the 'Daffodil Standards for Advanced Serious Illness and End-of-Life Care', created by the Royal College of General Practitioners and Marie Curie. To map activities to improve end-of-life care undertaken by GP practices, including the implementation of the Daffodil Standards. An online survey (Phase 1) has been made available to all GP practices in the UK to capture end-of-life care activities, experiences and challenges. Those who have signed up to receive guidance about the Daffodil Standards are also asked about their experiences of implementation and impact. Alongside this, a sub-sample of the survey responders are invited to take part in a semi-structured interview (n=20-26) to identify processes and mechanisms of implementation (Phase 2). This project is informed by the Normalisation Process Theory (NPT). Descriptive statistics (survey) and Framework Analysis (survey, interviews) are used to analyse the data. Sixty-eight surveys, of which 41% (n=28/68) had signed up to the Daffodil Standards, and five semi-structured interviews have been completed to date. Recruitment to both the survey and interviews is ongoing. The preliminary results of Phases 1 and 2 will be available for presentation in March 2023. The results will be used to inform and refine the design illustrative case studies to capture best available learning and identify exemplars of best practice for later phases of the study.

Risk-stratified breast cancer screening incorporating a polygenic risk score: a survey of UK GPs' knowledge and attitudes.

A polygenic risk score (PRS) quantifies the aggregated effects of common genetic variants in an individual. A 'personalised breast cancer risk assessment' combines PRS with other genetic and non-genetic risk factors to offer risk-stratified screening and interventions. Large-scale studies are evaluating the clinical utility and feasibility of implementing risk-stratified screening; however, GPs' views remain largely unknown. To explore GPs' knowledge of PRS and risk-stratified screening, attitudes towards risk-stratified screening, and preferences for continuing professional development. Cross-sectional online survey of UK GPs, July-August 2022, distributed by the Royal College of General Practitioners and via other mailing lists and social media. In total, 109 GPs completed the survey; 49% were not familiar with the concept of PRS. Regarding risk-stratified screening pathways, 75% agreed with earlier and more frequent screening for women at high risk; 43% neither agreed nor disagreed with later and less screening for women at lower-than-average risk; and 55% disagreed with completely removing screening for women at much lower risk. Eighty-one percent felt positive about the potential impact of risk-stratified screening towards patients; 62% felt positive about the potential impact on their practice. GPs selected training of healthcare professionals as the priority for future risk-stratified screening implementation, preferring online formats for learning. The results suggest limited knowledge of PRS and risk-stratified screening among GPs. Training - preferably using online learning formats - was identified as the top priority for future implementation. GPs felt positive about the potential impact of risk-stratified screening; however, there was hesitance and disagreement towards a low-risk screening pathway.

Trialling a Large Language Model (ChatGPT) in General Practice With the Applied Knowledge Test: Observational Study Demonstrating Opportunities and Limitations in Primary Care

Large language models exhibiting human-level performance in specialized tasks are emerging; examples include Generative Pretrained Transformer 3.5, which underlies the processing of ChatGPT. Rigorous trials are required to understand the capabilities of emerging technology, so that innovation can be directed to benefit patients and practitioners. Here, we evaluated the strengths and weaknesses of ChatGPT in primary care using the Membership of the Royal College of General Practitioners Applied Knowledge Test (AKT) as a medium. AKT questions were sourced from a web-based question bank and 2 AKT practice papers. In total, 674 unique AKT questions were inputted to ChatGPT, with the model's answers recorded and compared to correct answers provided by the Royal College of General Practitioners. Each question was inputted twice in separate ChatGPT sessions, with answers on repeated trials compared to gauge consistency. Subject difficulty was gauged by referring to examiners' reports from 2018 to 2022. Novel explanations from ChatGPT-defined as information provided that was not inputted within the question or multiple answer choices-were recorded. Performance was analyzed with respect to subject, difficulty, question source, and novel model outputs to explore ChatGPT's strengths and weaknesses. Average overall performance of ChatGPT was 60.17%, which is below the mean passing mark in the last 2 years (70.42%). Accuracy differed between sources (P=.04 and .06). ChatGPT's performance varied with subject category (P=.02 and .02), but variation did not correlate with difficulty (Spearman ρ=-0.241 and -0.238; P=.19 and .20). The proclivity of ChatGPT to provide novel explanations did not affect accuracy (P>.99 and .23). Large language models are approaching human expert-level performance, although further development is required to match the performance of qualified primary care physicians in the AKT. Validated high-performance models may serve as assistants or autonomous clinical tools to ameliorate the general practice workforce crisis.

Qualitative systematic review of general practitioners’ (GPs’) views and experiences of providing postnatal care

ObjectivesDevelop an understanding of the views and experiences of general practitioners (GPs) about their role in postnatal care, including barriers and facilitators to good care, and timing and content of...

Risk-Stratified Breast Cancer Screening Incorporating a Polygenic Risk Score: A Survey of UK General Practitioners’ Knowledge and Attitudes

A polygenic risk score (PRS) quantifies the aggregated effects of common genetic variants in an individual. A 'personalised breast cancer risk assessment' combines PRS with other genetic and nongenetic risk factors to offer risk-stratified screening and interventions. Large-scale studies are evaluating the clinical utility and feasibility of implementing risk-stratified screening; however, General Practitioners' (GPs) views remain largely unknown. This study aimed to explore GPs': (i) knowledge of risk-stratified screening; (ii) attitudes towards risk-stratified screening; and (iii) preferences for continuing professional development. A cross-sectional online survey of UK GPs was conducted between July-August 2022. The survey was distributed by the Royal College of General Practitioners and via other mailing lists and social media. In total, 109 GPs completed the survey; 49% were not familiar with the concept of PRS. Regarding risk-stratified screening pathways, 75% agreed with earlier and more frequent screening for women at high risk, 43% neither agreed nor disagreed with later and less screening for women at lower-than-average risk, and 55% disagreed with completely removing screening for women at much lower risk. In total, 81% felt positive about the potential impact of risk-stratified screening towards patients and 62% felt positive about the potential impact on their practice. GPs selected training of healthcare professionals as the priority for future risk-stratified screening implementation, preferring online formats for learning. The results suggest limited knowledge of PRS and risk-stratified screening amongst GPs. Training-preferably using online learning formats-was identified as the top priority for future implementation. GPs felt positive about the potential impact of risk-stratified screening; however, there was hesitance and disagreement towards a low-risk screening pathway.

1239. Hepatitis A Epidemiology in Europe: A Systematic Literature Review of the Last 20 Years

Abstract Background Hepatitis A (HepA) global burden is estimated to be &amp;gt; 100 million new cases/year. HepA is vaccine-preventable, but outbreaks still occur in regions with low endemicity such as Europe. Guidelines for HepA vaccination in adult risk groups are available in European countries, but adherence to vaccination recommendations is not systematically documented. Here we review European data on HepA infection outcomes, we discuss the HepA risk in the population in order to assess the adequacy of HepA vaccination strategies. Methods A systematic search in PubMed and Embase was performed from January 2001 to April 2021. Relevant data from ECDC, ProMED, ESCAIDE and national public health websites was also reviewed. We included articles in all languages, covering all ages and data published on 11 countries (Denmark, France, Germany, Greece, Hungary, Italy, the Netherlands, Spain, Sweden, Switzerland and the United Kingdom [UK]). Studies on seroprevalence and risk factors for HepA virus (HAV) were excluded. Results Overall, 134 articles and 85 grey literature reports were included in our review. In Europe, in the last 20 years, HepA infections were reported in all ages. Annual hospitalization rates exceeded 50% in 8 of the surveyed countries during 2016–2019. HAV complications were reported by 28 publications (ps): 8 liver transplantation cases in 6 ps ; liver failures in 0%–25% of HepA patients reported by 23 ps and hemorrhagic complications in 0%–51% of HepA patients reported by 8 ps. Fatality rates, reported by 12 ps for Italy, Hungary, Denmark, Germany and Spain were 0.05%–0.26%, mostly in adults/older adults. Conclusion In Europe, HepA infections are recorded in all ages despite not being consistently reported. Although the fatality rate is low, the hospitalization rates and the morbidity are high in adults/older adults. Considering the current epidemiological situation and HepA-related costs, authorities should raise awareness on HepA risk and adapt or improve compliance with the vaccination recommendations. Adherence to the existing recommendations should be monitored more closely. Universal HepA vaccination may be considered, similarly to the strategy adopted in the United States after widespread and ongoing HepA outbreaks. Funding GlaxoSmithKline Biologicals SA Disclosures Anar Andani, BSc, Medical director, GSK group of companies: Employee|GSK group of companies: Stocks/Bonds Eveline Bunge, PhD, GSK group of companies: My institution received grants and payment for developing studies Jennifer Eeuwijk, MSc, GSK group of companies: My institution received grants and payment for developing studies George Kassianos, MD (Hons), FRCGP, FESC, FBGTHA, FFTM RCPS(Glasg), FBHS, FHEA, FAcadMEd, DRCOG, LRCP (Edin.), LRCS (Edin.), LRCP&amp;S (Glas.), DMedAcup., DMedHypn., DFP, AstraZeneca: Advisor/Consultant|British Global and Travel Health Association: President|European Scientific Working Group on Influenza (ESWI): Board Member|European Scientific Working Group on Influenza (ESWI): Lectures|MSD: Advisor/Consultant|Northern European Conference on Travel Medicine: Lectures|Novavax: Advisor/Consultant|Pfizer: Advisor/Consultant|RAISE Pan-European Committee on Influenza: Chair|Royal College of General Practitioners: National Immunisation Lead|Sanofi Vaccines: Advisor/Consultant|Seqirus: Advisor/Consultant|UK National Health Service: Lectures|Valneva: Advisor/Consultant Robert Steffen, MD, GSK group of companies: Advisor/Consultant|GSK group of companies: Honoraria.

A short survey on GP practices’ approach (structure and process) for managing sepsis

Abstract Introduction Sepsis poses a challenge for general practice, and sepsis awareness raising amongst healthcare professionals is a priority, with general practices expected to have an identified sepsis lead who has updated staff.1 The Royal College of General Practitioners (RCGP) made sepsis a clinical priority to raise awareness of how appropriate GP action could have an impact.2 In September 2020, locality-based prescribing meetings were held focusing on sepsis. For the 2021/22 General Practice Prescribing Quality Scheme it was decided to ascertain what practices had in place to manage suspected sepsis. Aim To assess whether GP practices in Cornwall have the structure and processes in place to manage sepsis. Methods A pre-piloted paper survey, based on a literature review, was delivered to all practices. There were seven questions (mixture of closed questions and questions allowing expanded answers, and a free text comment option). The sepsis lead GP responded on behalf of the practice. Survey completion, along with completion of other elements of the Prescribing Quality Scheme, generated an incentive payment to practices. This service evaluation did not require ethical approval. Results Fifty-one of 57 (89%) surgeries responded. When asked if all practice staff were familiar with the terminology “Red Flag Sepsis’, 36 replied yes, 4 replied only clinical staff, and 11 no. Receptionist training on this topic had occurred in 33 practices, but not in 18. All 51 replied they had the necessary equipment readily available to assess patients with possible sepsis. As regards intravenous antibiotics routinely stocked in the practice, five had none, and for those that kept antibiotics it was a mixture of benzylpenicillin, ceftriaxone, cefotaxime or Tazocin. Thirty-seven were unable to take a blood culture prior to first dose of antibiotics for a patient with Red Flag Sepsis, including one highlighting such a patient would have immediate hospital referral. Fourteen answered yes to this question, including one also highlighting immediate hospital referral. Thirty-five practices had a safety-net resource aligning with NICE guidance3 for giving to adults, parents and carers being managed in the community, whilst ten said no and 5 clarified that they give verbal advice but no written information. Fifteen had implemented change in their practice that they would share with other practices though only 12 provided brief details. Free text comments generated themes around staff training, including administration of IV antibiotics by GPs, and whether practices should be taking blood cultures and associated practical issues. Discussion/Conclusion The RCGP states that ideally all staff in a sepsis aware practice will have had education about sepsis.2 We found this had not occurred in 18/51 (35%) practices, and in 11/51 (22%) practices staff appeared unfamiliar with the terminology “Red Flag Sepsis’. The issue of taking blood cultures (73% said they were unable to do this) generated concerns and further discussion with Microbiology colleagues is needed. Practices have identified actions to be taken subsequent to this survey. We recognise limitations of a small survey from late 2021 conducted in a single centre in England, possibly subject to social-desirability bias.

Conscientious Objection Based on Patient Identity

Conscientious Objection Based on Patient Identity

Discussing spiritual health in primary care and the HOPE tool—A mixed methods survey of GP views

In the UK, the General Medical Council (GMC) and Royal College of General Practitioners (RCGP) require doctors to consider spiritual health in their consultations. There are documented barriers to discussion of spiritual health, and suggested tools to help overcome them. To investigate how comfortable general practitioners (GPs) feel about discussing spiritual health in the consultation, and whether a structured tool (the HOPE tool) would be helpful. A mixed-methods online survey completed by GPs in England. A mixed methods online survey of practicing GPs in England asked about current comfort with the topic of spiritual health and use of spiritual history-taking tools. The acceptability of the HOPE tool was investigated using patient vignettes drawn from clinical practice. 177 GPs responded. 88 (49.71%) reported that they were comfortable asking patients about spiritual health. GPs felt most comfortable raising the topic after a patient cue (mean difference between pre and post cue 26%). The HOPE tool was viewed as acceptable to use with patients by 65% of participants, although its limitations were acknowledged. Qualitative data showed concerns about regulator (the GMC) and peer disapproval were major barriers to discussions, especially in the case of discordance between patient and doctor background. Only half of GPs are comfortable discussing spiritual health. Dedicated training, using a structured approach, with regulatory approval, may help overcome barriers to GPs discussing spiritual health. Further research into the benefits, and risks, of discussion of spiritual health in the GP consultation is recommended.

Case-mix and outcome variability in people with diabetic foot complications in England and Scotland

Abstract Background We assessed the difference in survival rates for people with diabetes experiencing LEA in England and Scotland, using large databases held by the Royal College of General Practitioners (RCGP) and the Scottish Diabetes Register (SCI-DC). Methods Observational retrospective study of T2D adults 18+ years with LEA between 1/1/2008-1/1/2018 from 1,800 general practices in England (7.4%) and all primary, secondary care units in Scotland. Significance tests were carried out using univariate odds ratios within each database. Results On 1/1/2018, N = 127,100 people with T2D were registered alive in RCGP, with N = 1,052 (832 per 100,000) experiencing prior LEA, vs N = 2,200 (783 per 100,000) out of 280,908 in SCI-DC. Among them, England recorded N = 405 patients (72.5%) with prior DFU diagnosis vs N = 993 in Scotland (74.3%), with a median time DFU to LEA of 2.0 vs 2.4 years. The median time spent with LEA was 3.4 years in England vs 3.9 years in Scotland. After including those dying earlier, different univariate patterns were found for England and Scotland. In both networks, increased risk was found for those aged 50+ at first LEA, with prior history of acute myocardial infarction, peripheral arterial disease, ischemic heart disease, cerebrovascular event, higher glomerular filtration rate and major LEA first. In England, reduced risks were found for males (OR = 0.77, 95%CI: 0.64-0.93) and people with retinopathy (0.69; 0.57-0.82), while higher risk were found for hypertension (1.29; 1.09-1.54). In Scotland, lower risks were found for obese (0.59; 0.52-0.66) and those with DFU after LEA (0.74; 0.62-0.89), vs higher rates among those of non-white ethnicity (1.63; 1.19-2.23) and dyalisis (2.31; 1.75-3.07). Conclusions Notable differences were found between England and Scotland in terms of characteristics associated with different outcomes following LEA among T2D adults. Multivariate analyses of aggregate patterns are currently ongoing to adjust for potential confounding. Key messages • Routine datasets from England and Scotland showed a differential impact of case-mix characteristics on lower extremity amputations among adults with Type 2 diabetes. • Information available from different clinical networks can be mapped against the available standard sets to compare health care outcomes of people with different complex conditions.

The GP and the veteran: the Royal College of General Practitioners' veteran-friendly programme

Retired brigadier Professor Robin G Simpson, veterans' champion at the Royal College of General Practitioners, discusses the veteran-friendly GP practice accreditation programme, and how it can improve care for veterans.

P68 Identifying the Content and Context of Pain Within Education and Training of General Practitioners

P68 Identifying the Content and Context of Pain Within Education and Training of General Practitioners