Pharmacy First, a national community pharmacy service, launched in January 2024 to improve access to primary care for patients with minor conditions facing backlogs caused by the COVID-19 pandemic. Pharmacies are required to share details about their consultations with general practices. To describe how and what clinical activity was recorded in general practice during the first year of the Pharmacy First service. With the approval of NHS England, we conducted a retrospective cohort study between 31 January 2024 and 30 January 2025 using OpenSAFELY-TPP, a secure platform for analysing pseudonymised GP records from practices using TPP software. We described patient demographics, Pharmacy First consultation trends, and the clinical conditions and medications coded with the consultations. A total of 402,165 Pharmacy First consultations were recorded for 340,710 patients from a general population of 26,142,380 registered patients in OpenSAFELY-TPP. Acute pharyngitis (28.9%) and uncomplicated urinary tract infection (28%) were the most frequently recorded conditions. By January 2025, 36.3% of recorded Pharmacy First consultations had a clinical condition, medication, or both. Females, younger adults and those living in more deprived areas were observed more often in Pharmacy First records compared to the general population. Increasing recording of the Pharmacy First community pharmacy service was observed in general practice records during its first year, particularly among younger and more deprived populations. However, variation in structured recording of consultation details may limit evaluation.
Background 20% of general practices in the England have closed or merged since 2013. Little is known about factors that are associated with these closures, despite evidence on their negative impacts. Understanding these risks is important for recovering general practice. Aim Describe how differences in the patient mix, practice location, workforce, funding and quality are associated with the future risk of closure Design and Setting Multilevel survival analysis of all general practices in England. Method All practices open on 1st April 2019 were followed until 1st April 2025 or closure. We gathered data on practice population characteristics, workforce, funding and quality. Cox proportional hazards models were used to analyse how these measures were associated with time to closure. Results Practice contract type and geographic location (region and rurality) were key factors associated with closures or mergers. For example, rates ranged from 3.7% to 19.7% by geographic region. Greater risk was associated with smaller practices, with a practice at the 10th percentile (3,032 patients) having 253% (95% CrI: 200%, 312%) higher risk of closure or merger than the median (7,256 patients). Greater risk of closure or merger was associated with losing or failing to gain patients (hazard ratio v medium increase 1.68 (95%CrI: 1.44, 1.96), lower baseline funding, poorer clinical quality, higher socioeconomic deprivation and certain contract types, but not the supply of general practitioners or nurses. Conclusion The practice contract, relevant region, practice list size, funding and quality are key hazards for the subsequent closure or merger of general practices.
Background To drive improvements in health care quality and to reduce inequalities, pay-for-performance (P4P) schemes have become widespread internationally. In recent years, most local commissioning bodies in the United Kingdom (UK) have developed their own local general practice incentive schemes. Aim To examine the use and effectiveness of local incentive schemes and their alignment to the national Quality and Outcomes Framework (QOF). Design and Setting This was a systematic review of qualitative studies related to local incentive schemes with a P4P structure within UK general practice in the UK after 2004. Methods Searches were conducted via OVID across the Embase and MEDLINE databases. Risk of bias was assessed using the EPOC criteria and a narrative synthesis was undertaken. Results 17 studies were identified focused on 14 local incentive schemes. All studies were from England, except one from Scotland. 5 studies included only tailored indicators, and 7 studies included both aligned and tailored indicators. Quality assessment suggested the current evidence was of mixed quality. All studies demonstrated positive impacts on process measures but health outcome measures were only evaluated in 9 studies showing inconsistent findings. 8 studies addressed impact on health inequalities and no studies addressed cost-effectiveness, patient reported outcomes or experience measures. Conclusion There is an emerging evidence base that local incentive schemes in general practice lead to improvements in process measures, although methodological quality of studies is mixed. Future studies should utilise more robust methods to evaluate effectiveness and examine impacts on health inequalities, cost-effectiveness and variation by practice.
Background Children are particularly vulnerable to healthcare-associated harm. Parents play a vital but under-recognised protective role in paediatric patient safety. Parent perceptions of and contributions to safety improvement efforts within hospital settings are well documented, but little is known about parent experiences and perspectives in primary care. Aim To explore diverse parental perspectives on paediatric safety in primary care and identify target areas for improvement. Design/Setting A qualitative study was conducted through online (n=2) and in-person (n=2) workshops with parents, taking place between June and July 2024. Method Workshops were structured around a descriptive analysis of paediatric patient safety incident reports in general practice. Parents discussed and reflected on their own experiences in relation to the findings. Thematic analysis of transcripts and field notes was conducted via NVIVO to identify key themes. Results Thirty-three parents from varied backgrounds, including under-served communities, participated. Three major themes are described: (1) Responsibility of care, highlighting perceived unclear roles between parents and healthcare teams; (2) Navigating the system, where parents described the need to 'fight' for care and the challenges of understanding healthcare processes; and (3) Communication and language, emphasising the difficulties of being heard, especially among ethnic minority parents and those lacking the confidence to speak up. Conclusion Parent perspectives on paediatric safety in primary care have highlighted key areas for practices, researchers and safety improvement teams to target system change and intervention development. Engaging parents as co-partners in these efforts could enhance trust, reduce risk, and improve safety outcomes for paediatric patients.
General practice (family medicine) experiences more violence and abuse by patients and the public than general hospital settings. Qualitative accounts on how violence and abuse are experienced and perceived remain limited in both breadth and depth. To explore 1. direct and indirect experiences of violence and abuse that general practice staff have encountered from patients and the public, and 2. its perceived impacts on staff well-being and their practice. This qualitative study was the second part of a mixed methods project, following an online nationwide survey. Participants were invited to an interview at the end of the survey. Data were collected via semi-structured interviews conducted between August and December 2023. Quantitative survey responses were extracted to describe the characteristics of participants, their experience of violence and abuse and feelings of safety and support at work. Interviews were transcribed and thematically analysed following the framework approach. Twenty-three general practice staff members participated, including 17 women and six men. Fifteen participants were in non-clinical roles and eight were clinicians. Six themes were identified: violence and abuse through direct interactions, violence and abuse beyond direct interactions, increased risk, individual impacts, occupational impacts, and impacts on care and services. Violence and abuse by patients and the public includes a wide range of behaviours. It has profound, and in some instances longstanding, impacts on staff, including constantly feeling unsafe and affected personal or social life, but also on clinical services, including staff turnover, and reduced service capacity.
Background The Older Women's Health Strategy for England highlighted the systemic under-representation of older women in healthcare. Over half of women over 80 are estimated to have osteoporosis, contributing to 180,000 fractures annually in the UK, with substantial personal and economic costs, despite clinically effective treatments and national guidelines being available. Aim To use insights from the experiences of older women and primary healthcare professionals to develop strategies to improve osteoporosis care. Design/Setting A community-based study in England, UK. Method Interviews with 30 community-dwelling older women (aged 70+) diagnosed with osteoporosis, and 31 healthcare professionals including GPs, physiotherapists, pharmacists, practice nurses, a healthcare assistant, and a community matron. We reviewed findings iteratively with our co-production group using a Constructivist Grounded Theory approach. Results Healthcare professionals acknowledged osteoporosis as clinically important but described limited knowledge and understanding. However, older women assumed expertise and proactive engagement from clinicians. Older women normalised symptoms as part of ageing frequently prioritising other co-morbidities. Most were unclear about their diagnosis, prognosis, or treatment plans. Self-management was expected but inadequately supported. There was little routine engagement with the wider primary care team. Digital communication further limited older women's engagement/re-engagement. Conclusion Osteoporosis remains poorly understood and inadequately managed in older women who face barriers, including multimorbidity, digital exclusion, and low self-efficacy. Many older women accept care gaps due to limited awareness and lack of meaningful interaction with healthcare professionals. Improved care navigation and greater involvement of the wider primary care team could enhance engagement and support better self-management.
People with intellectual disabilities (referred to as learning disabilities in the United Kingdom) face considerable health inequalities. One attempt to address these in England has been through incentivising General Practices to complete annual health checks with people with a learning disability aged 14 or over. We aimed to examine recent trends in learning disability registers and the uptake of learning disability annual health checks in England. Secondary analysis of publicly available data. We compiled and analysed NHS England data on the learning disabilities annual health check scheme from January 2022 to November 2025. The number of 14-17year-olds and adults on learning disability registers increased during this period by 30.49% and 14.53%, respectively. The most recent estimates indicate that around 0.588% of patients are on learning disability registers and 0.526% are also aged ≥14-years-old and eligible for annual health checks. The uptake of annual health checks increased slightly from 68.08% to 71.58% among 14-17-year-olds, and from 79.07% to 80.71% among adults. Uptake is lowest in the South-West and East of England, and highest in London, but is similar across deciles of patient deprivation and practice size. Ascertainment of people with a learning disability by primary care services appears to be improving but remains between a third and a quarter of prevalence estimates. The uptake of annual health checks among 14-17-year-olds continues to lag behind that of adults.
Background Timely diagnosis of cancer can be challenging as most present with non-specific symptoms in primary care. A third of those diagnosed with cancer report receiving a non-cancer diagnosis, before being referred for cancer investigations ('interim' diagnosis), presenting a potential missed diagnostic opportunity. Aim This study explored patients' experiences of receiving a non-cancer diagnosis prior to referral for investigation for suspected cancer. Design and Setting Secondary qualitative analysis of seven interview datasets collected in primary care in the UK since 2015. Method Patient journeys were summarised, charted and analysed using framework analysis. Patient Public Involvement and Engagement collaborators were involved throughout. Results 58 transcripts were included in which the patient presented to primary care with symptoms and received an interim non-cancer diagnosis. We identified eight common scenarios involving an initial non-cancer diagnosis followed by referral for suspected cancer. For example, individuals considered at low risk of cancer reported symptoms being linked to lifestyle factors, requiring multiple contacts over time before further investigation was considered. Patients queried interim diagnoses when they felt their symptoms and interpretations had been poorly understood, or they had been given inappropriate investigations or ineffective treatment. While patients recognised the difficulty of deciding when common symptoms required onward referral, they trusted clinicians who were responsive to their concerns, regardless of outcome. Conclusion Interim diagnoses arise as part of the normal diagnostic process in patients presenting with non-specific symptoms. Challenging these diagnoses in the face of new evidence could mitigate potential delays in diagnosis and improve patient outcomes.
Background Demand on emergency healthcare services is increasing. Utilising GPs in emergency ambulance services (EAS) may be effective in reducing avoidable conveyances to emergency departments and releasing emergency ambulances for higher-acuity cases. There is limited evidence on models of GP EAS roles in the UK. Aims To describe current provision of GP EAS roles and to develop a provisional explanatory programme theory. Design & Setting Qualitative realist interview study with professionals with detailed knowledge and experience of GPs working in EAS. Method Interviews were conducted with 27 participants to explore the mechanisms by which GP EAS roles produce their intended outcomes in different contexts. Results The GP role is predominantly to undertake enhanced remote patient assessment following an initial algorithmic triage, aiming to provide the most appropriate level of care. Whilst optimising the clinical response to individual callers, this also serves a system-level function by protecting ambulance resources to support timely responses to high-acuity patients. The mechanism behind GP-triage was explored through existing middle-range theories around risk individualisation, the process of translating organisational risk appetite to individual patient contacts. This helps the ambulance service make 'braver' decisions; those involving non-conveyance, alternatives to conveyance, or lower-acuity responses. GPs do this effectively due to their seniority, broad clinical knowledge and experience, approach to risk and uncertainty, ability to practice outside guidelines, consultation and communication skills, and system awareness. Conclusion GPs in EAS serve both individual patients and the system by individualising organisational approaches to risk and resource management.
Young people - aged 16-24 - are high users of digital technology. Online activity can be both beneficial for mental health and harmful. Appointments in general practice (GP) or primary care talking therapy provide opportunities to discuss online activity and its impact on mental health with young people. Such conversations could have preventive value by increasing awareness of problematic behaviours, identifying risk and suggest safer use strategies. However, little is known about whether such conversations are currently delivered in primary care. To explore practitioners views on discussing online activity and its role in the mental health of young people in primary care. Qualitative study with practitioners in GP and Talking Therapy Method: Semi-structured interviews with 24 practitioners, analysed using reflexive thematic analysis. Practitioners recognise helpful and harmful aspects to online activity, but there is variation in whether practitioners currently ask about online activity and whether they consider conversations appropriate for primary care. Several factors may shape confidence and decision making: practitioners own understanding of the online world; unable to change the impact on mental health or signpost to services; limitations in time, confidence or topic awareness. Practitioners identified a need for guidance and training to inform conversations about online activity. There is variation in whether conversations about online activity with young people are happening in primary care. The development of best-practice resources is required to ensure conversations are acceptable to young people and effective at changing problematic online activity to improve mental health.
The Additional Roles Reimbursement Scheme (ARRS), introduced by NHS England in 2019, aimed to expand the workforce, promote multidisciplinary team-based care, and improve patient outcomes. To examine changes in consultation rates and outcomes in relation to ARRS implementation, and compare outcomes across primary care roles. Longitudinal cohort study using the Clinical Practice Research Datalink (CPRD) AURUM, analysing 12,170,079 consultations (2015-21) from 600,000 randomly sampled patients at 400 English practices. Joinpoint regression modelled trends in age- and sex-standardised consultation rates, further consultations within 1-14 days, prescribing, and referrals. Multilevel regression compared outcomes between diagnostic-capable roles and general practitioners (GPs). Most consultations remained GP- or nurse-led, but rates with direct patient care (DPC)-ARRS-eligible roles increased, particularly for pharmacists, physiotherapists, and nursing associates. For paramedics and mental health practitioners, growth preceded formal ARRS inclusion, suggesting the scheme accelerated rather than initiated expansion. Most DPC-ARRS-eligible roles were consulted more frequently in less deprived areas, except physiotherapists. Compared to GPs, most DPC-ARRS-eligible roles delivered more consultations face-to-face (except pharmacists), had lower prescribing (except advanced nurse practitioners) and referral rates, and higher further consultation rates with a diagnostic-capable clinician within 1-14 days. However, all DPC-ARRS-eligible roles had lower odds of a further consultation specifically with a GP. ARRS has supported and accelerated the diversification of the primary care skill-mix. Patterns of consultation activity suggest an expansion of overall primary care capacity with some redistribution of workload across the multidisciplinary team, rather than a direct reduction in GP workload.
Individuals of Black heritage comprise 6.2% of the General Practice workforce in the UK. Representation is even lower in Primary Care Research. The understanding of why this misrepresentation exists is limited. We explored the representation of researchers of Black heritage at various career stages within primary care, alongside factors influencing retention and career advancement. Semi-structured interviews were conducted with 18 researchers of Black heritage and 7 primary care senior academic leaders (current or former heads of primary care departments in UK universities). Interviews explored representations within academic primary care, researcher career journeys, barriers and enablers to progression, and recommendations for improving diversity in the UK's primary care research workforce. Interviews were digitally audio recorded, transcribed and analysed thematically. All participants recognised significant underrepresentation of researchers of Black heritage in primary care research. Key barriers to career progression and retention included systemic and structural inequities, racism and exclusionary academic culture. Facilitators included proactive leadership, tailored training and support for researchers (including international scholars), mentorship, sponsorship and safe networking spaces. Participants offered recommendations to improve representation and career progression: training for leaders to recognise bias, discrimination and inequity, leadership development opportunities, tailored career support for researchers of Black heritage and targeted assistance for international researchers navigating UK academic systems. Visibility of Black role models in academic primary care was seen as essential to attracting and inspiring future researchers. These findings highlight key areas for change to foster a more inclusive and equitable research environment in primary care.
Gout is a prevalent chronic inflammatory disease associated with a substantial clinical and cardiovascular burden. Despite the availability of effective urate-lowering therapies (ULTs), gout management remains suboptimal. To describe clinical characteristics and treatment patterns, and to identify factors associated with long-term serum urate (SU) control in gout. Retrospective population-based cohort study using the primary care research database 'Sistema d'Informació per al Desenvolupament de la Investigació en Atenció Primària' (SIDIAP), covering >75% of the Catalan population within a universal healthcare system. Individuals with incident gout diagnosed between 2012 and 2023 were included. Demographic, clinical, and ULT data were collected. Good SU control was defined as SU levels <6 mg/dL for ≥80% of follow-up time. Factors associated with SU control were analysed. A total of 94 759 patients were included (mean age 66.25 [standard deviation 14.64] years; 79.58% male [75 412/94 759]; median follow-up 5.44 [interquartile range 2.54-8.24] years). In the 94 759 patients, hypertension (65.15%, n = 61 732), dyslipidaemia (50.58%, n = 47 932), diabetes (24.19%, n = 22 919), and chronic kidney disease (32.80%, 27 013/82 270 ) were common. Of the patients, 88.95% (n = 84 288) had ≥1 SU measurement. In total, 37.30% (35 343/94 759) had never received ULT. Allopurinol was the initial therapy in 96.09% of treated patients. Only 12.40% (10 453/84 288) achieved good SU control, with no improvement over time. Short ULT duration (≤25 days) occurred in 15.92% (9459/59 416) of patients. Good control was associated with longer treatment duration, higher allopurinol doses, febuxostat use, and better adherence, whereas delayed ULT initiation, male sex, obesity, chronic kidney disease, dyslipidaemia, and hypertension were associated with poor control. Long-term SU control in gout remains poor in primary care. Early initiation of ULT, appropriate dose optimisation, and improved adherence represent key modifiable targets to improve gout management.
Patient safety incidents (PSIs), defined as unintended or unexpected events that could have or did lead to patient harm, can have profound effects on general practitioners (GPs). Understanding how GPs experience and recover from PSIs is important for workforce wellbeing and patient safety in primary care. To explore how GPs experience PSIs, how they move on, and how they use available support. Qualitative study with GPs in England. Semi-structured interviews were conducted with 22 GPs. Data were analysed using thematic analysis. Participants were eligible if they had been involved in a PSI in general practice, spanning near misses to events resulting in patient harm. Themes were developed inductively and mapped onto the Theoretical Domains Framework (TDF) to identify cognitive, social, and environmental influences on learning, help-seeking, and recovery. Three themes were generated: personal and professional consequences, recovery and learning processes, and barriers to healing. GPs described emotional responses, including guilt, self-doubt, and fear of reputational or regulatory consequences. Peer support was valued, but access to structured support was limited. Formal investigations were experienced as distressing and compounded emotional impact. Recovery and learning were facilitated by empathetic, systems-focused cultures, protected time for reflection, and structured opportunities to learn from incidents. GPs rely on informal and self-directed strategies to recover from PSIs, with variable access to formal support. Recovery is shaped by individual and organisational factors. Findings highlight importance of compassionate, non-punitive support systems and psychologically safe environments to enable recovery and promote learning.
Pancreatic cancer has very low survival due to late diagnosis. Symptoms are often non-specific, complicating early detection in primary care. The Enriching New-Onset Diabetes for Pancreatic Cancer (ENDPAC) algorithm uses weight change, glycaemic control, and age at diabetes onset to identify new-onset diabetes (NOD) patients at increased pancreatic cancer risk. It was developed in the USA and has not been validated in the UK. Aim To validate ENDPAC in a UK primary care population and assess its predictive utility. Design and setting Retrospective cohort study using ORCHID, a national primary care sentinel network. Method Adults aged ≥50 with NOD and requisite glycated haemoglobin (HbA1c) and weight data were included. ENDPAC scores were calculated. Model performance was evaluated via discrimination, calibration, sensitivity, specificity, PPV and NPV. The Youden index identified optimal cutoffs. Sensitivity analyses assessed measurement timing, repeat HbA1c testing and multiple values. Results Among 70,050 individuals, 185 (0.26%) developed pancreatic cancer. Cases were older with higher HbA1c and greater weight loss at diagnosis. ENDPAC achieved an area under the curve (AUC) of 0.733. An optimal cutoff of ≥3 classified 27.6% of individuals as high-risk, with 62.6% sensitivity, 72.3% specificity, 0.6% PPV and 99.9% NPV. Sensitivity analyses showed similar performance across measurement windows and handling of multiple values. ENDPAC shows moderate discrimination in UK primary care. Although it has a relatively low PPV (0.6%), integration into routine systems could provide scalable, low-cost automated risk stratification, identifying people with NOD at higher pancreatic cancer risk as part of a sequential diagnostic pathway.
Background Polypharmacy is a global priority due to potential harms, including adverse drug events, hospitalisations and high treatment burden. Overall, these outcomes have shown little improvement despite numerous interventions indicating that current approaches to identify and manage polypharmacy remain insufficient. Aim To understand how polypharmacy is identified and managed in everyday primary care from patient, pharmacist and GP perspectives. Design and Setting Qualitative semi-structured interviews with 12 patients and 12 professionals (7 clinical pharmacists, 5 GPs) across Greater Manchester. Method Reflexive thematic analysis supported by Normalisation Process Theory and Constant Comparison as sensitisation tools. Results Polypharmacy was widely seen as important work but, in practice, inconsistent case-finding and unclear purposes for polypharmacy medication reviews were reported. Patients viewed medications as essential tools to sustain biopsychosocial elements of life, contrasting with practitioners' clinical priorities to mitigate potential harm. Polypharmacy work routinely contained layers of hidden complexity, which was often overwhelming and placed a heavy emotional burden on patients and professionals. Both patients and professionals required training and experience to effectively manage these complexities. Though a protocol-driven approach was sufficient for simple medication issues, only a longer-term approach, predicated on trust, continuity, relationships and open discussions encouraging healthy conflict, appeared to engage with deeper complexities. Conclusion Polypharmacy work is fraught with complexity and uncertainty, lacking standardised case-finding and clear purpose for both patients and professionals. Better models of care are needed to meet this challenge, encouraging a shift beyond a biomedically dominated protocol-driven approach to a more longitudinal and relational approach.
Maintaining doctor-patient relationship continuity remains a challenge in public primary care in Finland and internationally due to general practitioner (GP) workforce pressures and organisational constraints. To evaluate implementation of a named GP model and explain differences in implementation outcomes between two Finnish primary care units. A quasi-experimental before-after study was conducted in two Finnish primary care units with contrasting organisational settings. Patients were assigned a named GP responsible for non-urgent care. Electronic health record data covering physician consultations over 48 months were analysed. Continuity was measured using the Usual Provider of Care Index (UPC), the St Leonard's Index of Continuity of Care (SLICC), and the Own Patient Ratio (OPR). Implementation outcomes were interpreted using the RE-AIM framework. A segmented Interrupted Time Series (ITS) model was applied to OPR and SLICC, and UPC analysed using a pre-post design. Named GP continuity was higher in Tuira than in Pudasjärvi across all measures. In Tuira, adoption (OPR 0.88) was high and stable with lower named GP-level variation, while reach (SLICC 0.31) and effectiveness (UPC 0.35) improved but remained modest. Although continuity improved in Pudasjärvi, adoption remained weaker (OPR 0.40), reach lower (SLICC 0.16), and maintenance less stable. Continuity of care with physicians other than the named GP increased more in Pudasjärvi. The named GP model was functionally adopted in Tuira but remained largely nominal in Pudasjärvi. Health systems implementing named GP models should prioritise sustained GP presence and organisational alignment to achieve continuity.
Background Point-of-care tests (POCTs) are increasingly used to enhance diagnostic accuracy and facilitate rapid clinical decision-making in settings with limited laboratory access. However, there is currently no consensus on which POCTs should be routinely available in out-of-hours (OOH) primary care services. Aim To establish expert consensus on which POCTs should be considered essential or optional in European OOH primary care services. Design and Setting A modified Delphi consensus study involving an international panel of experts from 20 European countries, representing diverse clinical and academic backgrounds in OOH primary care. Method A three-round Delphi process was conducted. Round 1 assessed current POCT availability via questionnaire. In Round 2, panellists rated 28 POCTs as essential, optional, or unnecessary. In Round 3, results were discussed in a structured in-person workshop, followed by anonymous re-voting. Consensus was predefined as ≥66.6% agreement. Results Six POCTs achieved consensus as essential: blood glucose, urine dipstick, C-reactive protein (CRP), pregnancy testing, electrocardiography (ECG), and haemoglobin measurement. Twelve tests were classified as optional, while ten were deemed unnecessary. Key concerns included inappropriate use, variability in clinician confidence, and patient-driven demand. Conclusion This study provides the first European consensus on POCT prioritisation in OOH primary care. Implementation of essential POCTs, supported by training and governance, may improve diagnostic efficiency, while optional tests should be tailored to local service needs.
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