Scottish GP Research Articles

Patients' views on primary care multidisciplinary teams in Scotland: a mixed-methods evaluation.

Expanding primary care multidisciplinary teams (MDTs) was a key component of the 2018 Scottish GP contract, with more than 4700 MDT staff appointed since then. To explore patients' views on primary care MDT expansion in Scotland. A mixed-methods evaluation, which included a postal survey and semi-structured telephone interviews with patients in Scotland. A survey was undertaken of patients who had recently consulted a GP in deprived urban, affluent urban, and remote and rural areas, assessing awareness of five MDT roles and attitudes towards receptionist signposting. In addition, 30 individual interviews were conducted, exploring patients' MDT-care experiences. Of 1053 survey responders, most were unaware of the option of MDT rather than GP consultations for three out of five roles (69% unaware of link worker appointments; 69% mental health nurse; and 58% pharmacist). Reception signposting was less popular in deprived urban areas (34% unhappy versus 29% in remote and rural versus 21% affluent urban; P<0.001), and in patients with multimorbidity (31% unhappy versus 24% in non-multimorbid; P<0.05). Just over two-thirds of interviewees had multimorbidity and almost all reported positive MDT-care experiences. However, MDT care was generally seen as a supplement rather than a substitute for GP care. Around half of patients expressed concerns about reception signposting. These patients were more likely to also express concerns about GP access in general. Both of these concerns were more common in deprived urban areas than in remote and rural or affluent urban areas. MDT care has expanded in Scotland with limited patient awareness. Although patients understand its potential value, many are unhappy with reception signposting to first-contact MDT care, especially those in deprived urban areas living with multimorbidity. This represents a barrier to the aims of the new GP contract.

Primary care transformation in Scotland: a qualitative evaluation of the views of patients.

The new Scottish GP contract introduced in April 2018 aims to improve quality of care through expansion of the multidisciplinary team (MDT) to enable GPs to spend more time as expert medical generalists with patients with complex needs. To explore patients' views on the changes in general practice in Scotland since the inception of the new contract. Qualitative study with 30 patients (10 living in urban deprived areas, 10 living in urban affluent/mixed urban areas, and 10 living in remote and rural areas). In-depth semi-structured interviews with thematic analysis. Patients were generally unaware of the new GP contract, attributing recent changes in general practice to the COVID-19 pandemic. Ongoing concerns included access to GP consultations (especially face-to-face ones), short consultation length with GPs, and damage to continuity of care and the GP-patient relationship. Most patients spoke positively about consultations with MDT staff but still wanted to see a known GP for health concerns that they considered potentially serious. These issues were especially concerning for patients with multiple complex problems, particularly those from deprived areas. Following the introduction of the new Scottish GP contract, patients in this study's sample were accepting of first contact care from the MDT but still wanted continuity of care and longer face-to-face consultations with GPs. These findings suggest that the expert generalist role of the GP is not being adequately supported by the new contract, especially in deprived areas, though further quantitative research is required to confirm this.

Patients' experiences of GP consultations following the introduction of the new GP contract in Scotland: a cross-sectional survey.

The new Scottish GP contract commenced in April 2018 with a stated aim of mitigating health inequalities. To determine the health characteristics and experiences of patients consulting GPs in deprived urban (DU), affluent urban (AU), and remote and rural (RR) areas of Scotland. In 2022, a postal survey of a random sample of adult patients from 12 practices who had consulted a GP within the previous 30 days was undertaken. Patient characteristics and consultation experiences in the three areas (DU, AU, RR) were evaluated using validated measures including the Consultation and Relational Empathy (CARE) Measure and Patient Enablement Instrument (PEI). In total, 1053 responses were received. In DU areas, multimorbidity was more common (78% versus 58% AU versus 68% RR, P<0.01), complex presentations (where the consultation addressed both psychosocial and physical problems) were more likely (16% versus 10% AU versus 11% RR, P<0.05), and more consultations were conducted by telephone (42% versus 31% AU versus 31% RR, P<0.01). Patients in DU areas reported lower satisfaction (82% DU completely, very, or fairly satisfied versus 90% AU versus 86% RR, P<0.01), lower perceived GP empathy (mean CARE score 38.9 versus 42.1 AU versus 40.1 RR, P<0.05), lower enablement (mean PEI score 2.6 versus 3.2 AU versus 2.8 RR, P<0.01), and less symptom improvement (P<0.01) than those in AU or RR areas. Face-to-face consultations were associated with significantly higher satisfaction, enablement, and perceived GP empathy than telephone consultations in RR areas (all P<0.05). Four years after the start of the new GP contract in Scotland, patients' experiences of GP consultations suggest that the inverse care law persists.

Health inequalities, multimorbidity and primary care in Scotland

Scotland has an ageing population and the widest health inequalities in Western Europe. Multiple health conditions develop ∼10-15 years earlier in deprived areas than in affluent areas. General practice is central to the effective and safe management of such complex multiple health conditions, but the inverse care law has permeated deprived communities ('Deep End' general practices) for the past 50 years. A new, radical, Scottish GP contract was introduced in April 2018, which has a vision to improve quality of care through cluster working and expansion of the multidisciplinary team (MDT), enabling GPs to deliver 'expert generalism' to patients with complex needs. It states a specific intention to address health inequalities and also to support the integration of health and social care. Here, we discuss recent evidence for whether the ambition of the new GP contract, to reduce health inequalities, is being achieved.

Challenges in implementing GP clusters in Scotland: a qualitative study comparing the views of senior primary care stakeholders in 2016 with those in 2021.

Formation of GP clusters began in Scotland in April 2016 as part of a new Scottish GP contract. They aim to improve the care quality for local populations (intrinsic role) and the integration of health and social care (extrinsic role). To compare predicted challenges of cluster implementation in 2016 with reported challenges in 2021. Qualitative study of senior national stakeholders in primary care in Scotland. Qualitative analysis of semi-structured interviews with 12 senior primary care national stakeholders in 2016 (n = 6) and 2021 (n = 6). Predicted challenges in 2016 included balancing intrinsic and extrinsic roles, providing sufficient support, maintaining motivation and direction, and avoiding variation between clusters. Progress of clusters in 2021 was perceived as suboptimal and was reported to vary significantly across the country, reflecting differences in local infrastructure. Practical facilitation (data, administrative support, training, project improvement support, and funded time) and strategic guidance from the Scottish Government was felt to be lacking. GP engagement with clusters was felt to be hindered by the significant time and workforce pressures facing primary care. These barriers were considered as collectively contributing to cluster lead 'burnout' and loss of momentum, exacerbated by inadequate opportunities for shared learning between clusters across Scotland. Such barriers preceded, but were perpetuated by, the impact of the COVID-19 pandemic. Apart from the COVID-19 pandemic, many of the challenges reported by stakeholders in 2021 were predicted in 2016. Accelerating progress in cluster working will require renewed investment and support applied consistently across the country.

Exploring the Joint Association of Road Traffic Noise and Air Quality with Hypertension Using QGIS.

There is growing evidence linking exposure to air pollution and traffic noise with hypertension. The aim of this study was to examine the associations of registered hypertension cases and hypertension rate with exposure to air pollution and road noise. In this cross-sectional study, we linked the information from the NHS Scotland database of 776,579 hypertension patients' registrations and rates per 13.80 people at the Scottish NHS Board, HSCP, Cluster, and GP practice levels. Based on the geospatial attributes, the data on residential areas were added by modelling annual average air pollutant concentrations, including particulate matter (PM10 and PM2.5), nitrogen dioxide (NO2), and road-traffic noise at different frequency components (Lden). The relationships between exposure to road noise, air pollution, and hypertension were examined using multiple regression and multivariate analysis. Traffic noise and air pollution at various frequency components positively and negatively predicted registered hypertension cases and hypertension rate. Based on the canonical loading technique, the variance explained by the canonical independent variable at a canonical correlation of 0.342 is 89%. There is a significant correlation between joint air pollution and noise at different frequency components and combined registered hypertension cases and hypertension rate. Exploring the combined effects of the two environmental exposures and the joint modelling of noise and air pollutants with hypertension in geospatial views provides an opportunity to integrate environmental and health data to support spatial assessment strategies in public and environmental health.

Primary care transformation in Scotland: qualitative evaluation of the views of national senior stakeholders and cluster quality leads.

Primary care transformation in Scotland aims to improve population health, reduce health inequalities, and reduce GP workload. Two key strategies (formalised in April 2018 in the new Scottish GP contract [Scottish General Medical Services contract], although started in early 2016) are the expansion of the multidisciplinary team (MDT) and GP cluster working. To explore progress in the implementation of the GP contract in Scotland in terms of the MDT and cluster working. Qualitative study with key national primary care stakeholders (PCSs) (n = 6) and cluster quality leads (CQLs) in clusters serving urban high deprivation areas (n = 4), urban mixed areas (n = 4), and remote and rural areas (n = 4). Semi-structured interviews with thematic analysis. There was general support for the initial aims of the new GP contract but all interviewees felt that progress on both MDT expansion and cluster working was slow, even before the pandemic. None of the CQLs (and few PCSs) felt that GP workload had reduced significantly, nor that the care of patients with complex needs had improved. Lack of time and poorly developed relationships were key barriers, as was a lack of relevant primary care data, and additional support (including guidance, administration, training, and protected time). Key PCSs and CQLs in different areas of Scotland report limited progress in primary care transformation, only partly related to the pandemic. There is a need for better workforce planning and support if the new GP contract is to succeed in transforming primary care in Scotland.

An Audit on Patient Safety and Prescribing in Patients With a Learning Disability, Autism, or Both at a Scottish GP Practice

AimsThe aim was to investigate the proportion of patients with a previous diagnosis of learning disability or autism who later successfully underwent an annual review of their prescribed anti-psychotic or anti-depressant. This audit was prompted after Public Health England announced that a significant number of adults with a learning disability, autism or both take a prescribed antipsychotic, an antidepressant or both without appropriate clinical indications (psychosis or affective/anxiety disorder).MethodsThe sample included 23 patients from the practice who had received a diagnosis of learning disabilities, autism, or both by 12th October 2020. Of these, 12 patients had a record of at least 5 prescriptions of an anti-psychotic in the last 12 months and 20 patients had a record of at least 5 prescriptions of an anti-depressant within the last 12 months. The notes for these patients were reviewed in May 2021 in an effort to ascertain whether a medication review had been completed for these patients since May 2020. The review process included a phone call between the patient and the prescribing doctor to determine whether there any side effects were being experienced and to assess the need for the continuation of the prescription. The resulting data were recorded and analysed on Microsoft Excel.ResultsOut of the 12 patients who had been prescribed an anti-psychotic, 10 had received a medication review within the last 12 months. From the 20 patients who had been prescribed an anti-depressant, 19 had undergone a review of their medication within the last 12 months.ConclusionReview of anti-psychotics and anti-depressants prescribed to patients with a diagnosis of learning disability, autism, or both was overall positive with the majority of these patients receiving a medication review within 12 months. As a further recommendation, another audit can be done to explore whether these patients had an annual blood test done as increased cholesterol is a known side-effect of psychotropic drugs.

Collaborative improvement in Scottish GP clusters after the Quality and Outcomes Framework: a qualitative study.

BackgroundScotland abolished the Quality and Outcomes Framework (QOF) in April 2016, before implementing a new Scottish GP contract in April 2018. Since 2016, groups of practices (GP clusters) have been incentivised to meet regularly to plan and organise quality improvement (QI) as part of this new direction in primary care policy.AimTo understand the organisation and perceived impact of GP clusters, including how they use quantitative data for improvement.Design and settingThematic analysis of semi-structured interviews with key stakeholders (n = 17) and observations of GP cluster meetings (n = 6) in two clusters.MethodThis analytical strategy was combined with a purposive (variation) sampling approach to the sources of data, to try to identify commonalities across diverse stakeholder experiences of working in or on the idea of GP clusters. Variation was sought particularly in terms of stakeholders’ level of involvement in improvement initiatives, and in their disciplinary affiliations.ResultsThere was uncertainty as to whether GP clusters should focus on activities generated internally or externally by the wider healthcare system (for example, from Scottish Health Boards), although the two observed clusters generally generated their own ideas and issues. Clusters operated with variable administrative/managerial and data support, and variable baseline leadership experience and QI skills. Qualitative approaches formed the focus of collaborative learning in cluster meetings, through sharing and discussion of member practices’ own understandings and experiences. Less evidence was observed of data analytics being championed in these meetings, partly because of barriers to accessing the analytics data and existing data quality.ConclusionCluster development would benefit from more consistent training and support for cluster leads in small-group facilitation, leadership, and QI expertise, and data analytics access and capacity. While GP clusters are up and running, their impact is likely to be limited without further investment in developing capacity in these areas.

A 20-year observational cohort of a 5 million patient population-Tonsillectomy rates in the context of two national policy changes.

(a) To report national trends for tonsillectomy, tonsillitis, peritonsillar abscess and deep neck space infection in secondary care. (b) To report national trends in sore throat consultations in primary care. (c) To report national trends in antibiotic prescribing in both primary and secondary care between 2011 and 2015. Retrospective nationwide cohort study. Data requested from Information Statistics Department (ISD) Scotland for tonsillectomy, tonsillitis admissions, peritonsillar abscess admissions and deep neck space infection (DNSI) admissions in Scotland, between 1993/94 and 2015/16. Data for antibiotic prescriptions in general practice and hospital admissions between 2011 and 2015. Scottish ENT departments and GP practices. Scottish patients who underwent tonsillectomy or were admitted to hospital with tonsillitis, peritonsillar abscess or deep neck space infection. Scottish patients that attended their GP with tonsillitis. Tonsillectomy rates between 1993/94 and 2015/16 decreased by 48% (P<0.001). Over the same time period, there has been a corresponding 136% increase in tonsillitis admission (P<0.001) and a 167% increase in peritonsillar abscess admissions, (P<0.001). Between 1996/97 and 2015/16, there was a 500% increase in deep neck space abscesses (P<0.001). There has been a significant decrease in tonsillectomy rates over the past two decades. Over the same time period, there has been a significant increase in admissions to secondary care with tonsillitis, peritonsillar abscess and deep neck space infection. These changes have happened in the context of two separate national policies being introduced-Scottish Intercollegiate Guideline Network (SIGN) guidelines for management of sore throat and the Scottish Reduction in Antibiotic Prescribing.

The expert medical generalist.

The proposed new Scottish GP contract1 has suggested that GPs be considered ‘expert medical generalists’ (EMGs). Helen Stokes-Lampard, Chair of the Royal College of General Practitioners (RCGP), has named GPs ‘consultants in general practice’.2 These new titles beg the question of whether they are granted simply for the completion of vocational training involving 18 months in the field in which we are experts, after a total of 3 years’ training post-foundation, or whether there is more involved in developing this expertise. Much importance has been placed on the regard with which general practice is held within universities and hospitals, and its effect on GP recruitment, and so it is likely that unfavourable comparisons will be drawn between the experience and training required to become a consultant in general practice and a consultant in anything else. Although not based on any evidence, Malcolm Gladwell’s 10 000-hour expert theory,3 representing as it does about 5 years of full-time general practice, would, nonetheless, accord with the time at which many of us begin to feel that we have obtained some mastery of our subject. Gladwell’s theory, however, does not simply mean working at the job for 10 000 hours but practising, that is, actively pursuing improvement in order to become expert. This aspect bears some closer consideration. Reeve et al 4 describe three different views of the GP role and suggest that there are …

Administrative mass data linking minimal/zero false positives

ABSTRACT&#x0D; ObjectivesPart of eHealth project in Scotland to assign a health index to all electronic patient records. One off extracts from live and historical records were posted to a record linkage department where deterministic and Newcombe probability mass matching was performed to assign the Scottish GP registration (CHI) number. These were real world administrative matches with emphasis on minimal false positives rather than maximum acceptable match rates.&#x0D; ApproachEarly investigations examined the causes of false positive matching. A running window of incomer match scores, instead of only the highest pair score indicated that highest pair Binit scores, even well above acceptance threshold yielded spurious matches and that lower scoring pair matches for the same incomer were more acceptable. A single threshold would not work. The customers were invited to clerically check the matches; their heuristic strategies were observed and incorporated into an automated partitioning exercise.&#x0D; ResultsDeterministic match rates below 70% were considered very poor. 70-80% poor, 80-85% average, 85-90% good, &gt;90% excellent. The residual unmatched incomers were processed using Newcombe methods, then through the partitioning exercise. 90-95% (deterministic+residual) match rates were viewed as average, 95-98 % as good, 98-100% as excellent. Several deterministic match runs were passed through the residue process early in the exercise, any false positive thrown up by this caused a change in the deterministic process to eradicate errors. Roughly 1000 linkage exercises were done for the eHealth project.&#x0D; ConclusionsThis was a joint exercise where the linkage department delivered potential match pairs to the customer. The customer then decided on the partitions they were willing to accept. All the potential pairs were sent with a checking engine to view the outcome. Most elected to accept only deterministic matches. Some accepted linkage department advice; often the linkers would clerically flag accepted and rejected pair matches for the customers to review. There was a pilot administrative matching project to assign the health index to social service data in Scotland called eCare which started after the eHealth exercise; in both, the customers were requested to alert us with any false positives - no alerts were received. The same methods were used in the recent exercise to de-duplicate and merge all Glasgow's hospital records; the customer was very used to the methodology, so more checking work by the linker was accepted to achieve higher match rates. A method to estimate false positive rates is proposed.

New pharmacotherapy service to be set up as part of Scottish GP contract

New pharmacotherapy service to be set up as part of Scottish GP contract

Revision of Scottish GP contract removes one in four QOF points

Changes to the GP contract in Scotland have been agreed for 2014-15, including the removal of one in four points from the Quality and Outcomes Framework (QOF).1 As part of the changes, agreed by the British Medical Association’s Scottish General Practitioners Committee and the Scottish government, 264 points will be removed from QOF, leaving a total of 659 points. To offset funding lost through …

Training the rural GPs of the future

Ronald MacVicar and colleagues look at a new option for 2012: the Scottish rural-track GP specialty training programme

William Mackintosh Mackean

Bill Mackean seemed to want to keep to surgery hours from the moment he came into the world, in the family house at 55 Shaw Street, Everton, on 20 July...

Knowing me, Knowing you: personality and peer appraisal

Since the inception of the national system in 2002, the Scottish GP appraisal process has been underpinned by educational principles of reflection on current practice, evidence of learning and its implementation in daily practice to improve patient care. To encourage reflection and learning by appraisees in Scotland, GP appraiser training is evolving to improve the skills of appraisers.1 The aim is to encourage appraisee reflection and learning by providing appropriate personal and professional challenges and constructive feedback in preparation for enhanced appraisal for revalidation. While most appraisals end in positive outcomes, evaluation using the GP Scot 3a (appraisee) and 3b (appraiser) electronic feedback database sometimes indicates a difference between the two peers' impression of the appraisal interview. Could this disparity be attributed to unknown differences in personality and doctors' communication styles? Since 2008, facilitated workshops have identified variation across four key domains of the appraisal process: appointments, paperwork, interviewing and feedback, where personality was perceived to result in particular behaviours. Formal awareness-raising of personality issues may therefore add value to appraisal training. The Myers-Briggs type indicator (MBTI®) is a psychometric test used world-wide.2 Developed by Katharine Briggs and Isabel Myers from theories developed by Carl Jung in the 1900s, MBTI has been extensively tested for reliability and validity. The Scottish GP appraisal scheme has developed workshops on MBTI training to increase appraisers' awareness of their personal styles and preferences. Key objectives are to enable appraisers to understand and value others by first appreciating the importance of understanding themselves. Further, where differences arise, appraisers are encouraged to adapt to meet their colleagues' needs in order to establish rapport and ensure that the appraisal maximises the potential for reflection, the collection of evidence, and construction of a personal development plan. The MBTI is a questionnaire, which assesses eight preferences derived …

Verifying appraisal evidence using feedback from trained peers: views and experiences of Scottish GP appraisers

GP appraisal is currently considered inadequate because it lacks robustness. Objective assessment of appraisal evidence is needed to enable judgements on professional performance to be made. To determine GP appraisers' views of the acceptability, feasibility, and educational impact of external peer feedback received on three core appraisal activities undertaken as part of this study. Independent peer review and cross-sectional postal questionnaire study. NHS Scotland. One of three core appraisal activities (criterion audit, significant event analysis, or video of consultations) was undertaken by GP appraisers and subjected to peer review by trained colleagues. A follow-up postal questionnaire elicited participants' views on the potential acceptability, feasibility, and educational impact of this approach. Of 164 appraisers, 80 agreed to participate; 67/80 (84%) submitted one of three appraisal materials for peer review and returned completed questionnaires. For significant event analyses (n = 44), most responders believed the peer feedback method was feasible (100%) and fair (92.5%) and would add value to appraisal (95.5%). Peer feedback on criterion audits (n = 15) was believed to be acceptable and fair (93.3%) and it was thought it would be a useful educational tool (100%). Completing a consultation video (n = 8) was perceived to be feasible as part of normal general practice (n = 5). It was unanimously agreed that assessment of videos by peers has educational impact and would help improve appraisal. This group of GP appraisers strongly supported the role of external and independent feedback by trained peers as one approach to strengthening the existing appraisal process.

Minister blocks private companies from buying Scottish GP services

Minister blocks private companies from buying Scottish GP services

The effectiveness of national influenza vaccination policies for at-risk populations over 5 seasons in a Scottish general practice

To determine the effectiveness of serial influenza vaccination. Studied in a Scottish GP population, the overall seroresponse rate increased with annual influenza vaccinations and after 5 years it increased from 45.1% to 93.3% for influenza virus A (H1) and from 48.4% to 98.3% for influenza virus A (H3). However, there was little boosting effect with further doses after becoming a seroresponder. The pre-vaccination titres were significantly higher in previous year's seroresponders compared to non-responders. The policy of annual vaccination is supported by our data in order to increase the disappointing response rate after one dose. However, the lack of a boosting response with subsequent doses and the significant residual immunity after becoming a seroresponder suggests a prior serological immunity check in order to better direct the vaccine supply (in the years of no antigenic drift), to those who need it most.