Background Prioritisation is an increasing part of a GP's workload, though learning this skill is usually left to on-the-job training. Little is known about how experienced GPs prioritise their workload. Aim This study aimed to explore the factors that experienced GPs consider when prioritising their acute workload Design and Setting This qualitative research study used focus groups of GP educators based in central Scotland to explore the factors that they consider when prioritising their acute workload. Method Participants were recruited through convenience sampling. The key inclusion criterion was being involved in the supervision of GP Registrars. Five focus groups were carried out and transcripts were analysed using reflexive thematic analysis to identify the dilemmas that GPs face when prioritising their workload. Results Thirty-seven participants took part. Five themes emerged from the data; (1) GPs maintain an awareness of their work system and adapt their consultation style to demand. (2) They make decisions in an order which manages their time efficiently. (3) Their familiarity with patients and clinical experience enables them to make quick decisions about patient care, though this can lead to bias in decision-making. (4) They rely on their therapeutic relationships with patients and working relationships with colleagues when making decisions. (5) Their personal preferences are important, such as managing the simplest or the most complex presentations first. Conclusion Prioritisation is an increasingly important skill in modern General Practice. It is crucial that those involved in prioritisation are given the time and tools necessary to adequately develop this skill.
Funding based on population need is key to equitable healthcare. The formula for general practice capitation payments in England has not been updated for over twenty years and is based on crude workload weights. To estimate and describe the uplifts in payments required to bring practices in line with updated and more precise needs-based workload weights. All 6,213 general practices in England in 2024. We applied updated workload weights to publicly available practice data on patient age and gender, new registration, ethnicity, deprivation and prevalence of 20 long-term conditions. We removed the practice payment provided for input price variation and calculated the current workload payment per weighted-patient for each practice and the funding required to uplift all practices to minimum thresholds. Workload payment per-patient was £92.66 on average, varying from £86.72 in the lowest to £99.91 in the highest deprivation decile. Workload payment per-weighted-patient varied from £81.40 (5th percentile) to £107.10 (95th percentile) and from £89.69 in the lowest to £96.40 in the highest deprivation decile. Uplifting payments to a minimum of £102.46 per-weighted-patient (90th percentile value) would increase total payments by 11.6% (£677.77M per year) and payments per-patient to £99.75 in the lowest and £108.18 in the highest deprivation decile. The workload element of the general practice funding formula should use updated weights. Additional concerns related to equity in outcomes and under-funding of practices in deprived areas should be addressed by adjustments or revisions of other elements of the funding formula.
Background Patients later diagnosed with cancer may first be diagnosed with another 'interim' diagnosis based on their clinical presentation. In some cases, interim diagnoses may be missed opportunities to diagnose cancer. Aim To explore healthcare professionals' perspectives of when interim non-cancer diagnoses occur, how they impact a cancer diagnosis, and what could trigger their prompt review. Design and setting Interviews were conducted between March and November 2024 with 35 General Practitioners (GPs), 3 other clinicians, and 3 practice administrators from 31 general practices in Southern England, UK. Method Semi-structured interviews via videocall. Interviews were analysed using Framework Analysis. Results Participants reported that interim diagnoses occurred in cases of diagnostic uncertainty, especially when non-specific symptoms were attributed to common differential diagnoses. Remote consultations were thought to increase the likelihood of interim diagnosis by limiting information gathering. Interim diagnoses were suggested to delay cancer diagnoses, although this was not always seen as avoidable. Clinicians hoped to facilitate opportunities to make a cancer diagnosis by using safety-netting to encourage reattendance, and an informal rule of "three strikes and you're in". Colleagues providing a "fresh pair of eyes", discussing diagnostic uncertainty in the clinical team, and using past cases as learning opportunities were suggested approaches to facilitate prompt review of interim diagnoses. Conclusion Consistent safety-netting is required to ensure timely review of non-cancer 'interim' diagnoses when there is a possible underlying cancer diagnosis. The range of interim diagnoses and their impact on cancer diagnosis requires further quantification to inform interventions to mitigate their effect.
Background Heart failure (HF) is a global public health priority. HF diagnosis in primary care is linked to improved outcomes, but most patients are diagnosed in hospital. The pathway to HF diagnosis in primary care is poorly understood. Aim To gain deeper understanding of the patient experience of missed opportunities for HF diagnosis. Design and Setting Qualitative study with patients recruited through general practice and community nurse clinics. Method We conducted, remote, semi-structured interviews with 24 patients who had a diagnosis of HF. Data were analysed using reflexive thematic analysis. Results Three themes were developed: diagnostic liminality and suffering at the threshold of HF diagnosis (when participants were unwell but not yet diagnosed or were unaware of their diagnosis); meaning and framing in the diagnostic moment; and truth-telling and sense-making facilitating the escape from liminality. Although receiving the diagnosis brought relief, it also came as a shock due to the meanings associated with the term. Some thought HF meant imminent death and was incompatible with living. Participants also described not being properly informed about their diagnosis. Conclusion While life was disrupted by a HF diagnosis, the diagnosis did not enable the transition from liminality. It was truth telling, in combination with careful explanation that facilitated the shift from diagnostic liminality. Through sense-making, participants were able to build an understanding of what HF diagnosis actually meant for them and their future. Clinicians have a vitally important role in guiding patients away from diagnostic liminality through prompt HF diagnosis and thoughtful communication.
Background It is widely recognised that continuity of GP care should be improved. This requires a continuity measure, applicable in all practices. Previous measures have limitations. Aim To develop an improved measure of continuity and compare its performance with established measures. Design and Setting One-year pilot in two general practices using audit data. Method The modified SLICC (mSLICC) was developed, calculated monthly and compared with the St Leonard's Index of Continuity of Care (SLICC), the 1-year Bice-Boxerman (BB) and Usual Provider of Care Index (UPC). Proportions of patients and appointments included were calculated with patients grouped by age, 3-year appointment numbers and frailty categories. Results In the two practices, the mSLICC included 19,840 out of 29,127 (68.1%) appointments and a mean of 65.2% (SD 6.4%) of patients with appointments. The UPC/BB included 21032 (72.2%) appointments and 4096 (41.2%) of 9924 patients with appointments. In practice A the mSLICC was 52.0%, SLICC 57.1%, mean UPC 0.63 (95% CI 0.62 to 0.64), and mean BB 0.41 (95% CI 0.40 to 0.43). In Practice B the mSLICC was 25.7%, SLICC 25.1%, mean UPC 0.50 (95% CI 0.49 to 0.51), and mean BB 0.23 (95% CI 0.22 to 0.25). The mSLICC correlated with the SLICC [(r)=0.98, p<0.001]. Conclusion The mSLICC is a new monthly measure of continuity. It has fewer limitations than the BB and UPC and does not require a named GP. With sufficient IT resource, the mSLICC could be used by practices without personal lists to measure continuity of care.
Functional abdominal pain (FAP) and irritable bowel syndrome (IBS) are associated with anxiety, depression, school absenteeism and reduced quality of life in children. In secondary care, hypnotherapy is often available. To determine the effectiveness of home-based guided hypnotherapy for children with FAP or IBS in primary care. A pragmatic randomised controlled trial in Dutch primary care with a follow-up of 12 months. Children aged 7-17 years with FAP or IBS diagnosed by a general practitioner were included. The intervention group received home-based guided hypnotherapy via a website for 3 months in addition to care as usual. The control group received care as usual only. The primary outcome was adequate relief of abdominal pain and/or discomfort at 12 months. Adjusted odds ratios (aOR) and 90% confidence intervals (90%CI) are reported. In total, 152 children were included. No significant differences were observed in adequate relief at 12 months (79.5% in the intervention group (58/73 children) versus 74.3% in the control group (52/70 children); aOR 1.47, 90%CI 0.74-2.93), but more children in the intervention group had adequate relief compared to the control group at 3 months (aOR 2.74, 90%CI 1.22-6.13) and 6 months (aOR 4.26, 90%CI 1.81-10.04). The intervention group also showed reductions in abdominal pain severity, intensity, frequency, and threat, and higher proportions of fast sleep onset. While adequate relief after 12 months is high in both groups, adding hypnotherapy to care as usual may help achieve earlier relief and reduce pain.
Background Personal continuity -having a GP who knows and follows the patient- is a core value of general practice, yet changes in society and healthcare have challenged its provision. Therefore, we developed TOOL-kit, a multi-component intervention aimed to optimise personal continuity for patients aged 65 or above. Aim to evaluate TOOL-kit's implementation and identify barriers and facilitators influencing its delivery. Design and setting Mixed-methods study embedded in the main effect trial (August 2020 - April 2022). Method Implementation was assessed via 3-monthly surveys, 93 interviews with GPs and practice staff (n=221) from 32 general practices. Based on Saunders paradigm, it was evaluated on the process indicators of recruitment and reach, fidelity (adherence to protocol), dose delivered (extent of improvement plans), and dose received (goal achievement, sustained organisational change). Barriers and facilitators were evaluated on the intervention, staff, organisational, and socio-political levels. Results Of 32 practices, 23 adhered to protocol. TOOL-kit was delivered at a (very) low dose in 17 of 31 practices. At study end, 55% of practice goals were met. After 24 months, 19 practices had observed sustained positive effects regarding personal continuity. A good quality improvement infrastructure facilitated TOOL-kit implementation, while work pressure and staff shortages, exacerbated by COVID-19, were seen as the main barriers for implementation. Conclusion Despite implementation challenges, TOOL-kit was able to enhance work procedures and improve the focus on personal continuity within practice. Fostering practices' quality improvement infrastructure and decision-making processes could improve implementation. Keywords General Practice, Continuity of care, Implementation Science, Physician-Patient Relations.
Background Domestic and family violence (DFV) is common worldwide and general practitioners (GPs) are not immune. DFV survivors frequently present to primary care where GP DFV survivors often encounter them. Little literature and no qualitative studies look at the emotional and professional effects that these encounters have on survivor GPs, including how it affects their ability to care for survivor patients. Aim This study asked the question, "what are the experiences of survivor GPs when working with patient survivors of DFV?" Design/Setting This study used a phenomenological qualitative approach to gain a deep understanding of Australian GP DFV survivors' experiences when working with survivor patients. Method Participants were Australian GPs self-identifying as survivors of all forms of DFV. Participants were recruited from two Australian GP online groups using purposive sampling. Semi-structured interviews took place and were audio recorded and transcribed verbatim. Reflexive thematic analysis was undertaken. Results Participants (20) were female and worked in a range of locations throughout Australia. Four themes were identified: 'My experiences can be my superpower' (encompassing the subthemes: 'Having a sixth sense' and 'Going above and beyond'); 'Connecting with survivor's stories'; 'Wearing a cloak'; and 'My experiences give me purpose'. Conclusion Although GP DFV survivors commonly experienced difficult emotions when working with survivor patients, they had a commitment to this work which stemmed from personal DFV experiences. This increased their empathy for survivors and gave them a deep understanding of their circumstances, allowing them to work powerfully with survivors, aiming to improve their situation.
Structured Medication Reviews (SMRs) were introduced into primary care in England for patients living with multiple long-term conditions (MLTCs), polypharmacy, increased frailty, in care homes or at risk of medicines-related harm. SMRs aim to optimise the therapeutic potential of medication and reduce medicine-related harms through holistic reviews. To explore the day-to-day work being undertaken with, and by, clinical pharmacists to implement, embed and integrate SMRs into practice, and consider how to optimise SMRs. Qualitative one-to-one interviews with clinical pharmacists undertaking SMRs and SMR service leaders/managers (SMR leads) in England between February 2023 and November 2024. Participants were recruited as part of a wider evaluation of the roll-out of SMRs in England. Interview topic guides and qualitative data analysis were informed by Normalization Process Theory (NPT). Eighteen clinical pharmacists and five SMR leads participated. Participants reported often having to explain the purpose of SMRs and clinical pharmacists' roles to patients, partly due to patients not being informed about SMRs. Participants valued SMRs and expressed that trust-building and tailored consultations were important for optimising medications. Integration varied due to high workload, inconsistent leadership support, inadequate administrative/pharmacist technician resource and lack of training. However, participants described SMRs as valuable for identifying and addressing unmet needs and supporting holistic, person-centred care across MLTC pathways. The findings demonstrate the need for improved information on SMRs for patients and primary care teams, adequate and appropriate resource allocation, and enhanced support for consultation skills training to optimise medicines use.
Background Chronic kidney disease (CKD) affects approximately 10% of adults in England. <1% progress to end stage-kidney disease (ESKD), significantly impacting health-related quality of life with high healthcare costs. CKD is associated with increased cardiovascular disease risk. New therapies to improve outcomes highlight the need for effective risk stratification. Aim To explore primary care teams' views and experiences of CKD risk stratification. Design and Setting Qualitative interview and focus group study with GP practices in South England, South London and Yorkshire. Method 26 semi-structured interviews with GPs, pharmacists and practice nurses, and 4 focus groups (31 participants) with practice teams including clinical, administration and management staff, February 2024 to January 2025 across 20 practices, informed by normalisation process theory (NPT), using thematic analysis. Results We identified 4 key themes: 1) Awareness of diagnostic criteria and risk stratification tools, 2) Value of coding CKD and discussion of risk, 3) Barriers to CKD risk stratification, 4) Improving CKD risk stratification. Despite universal awareness of diagnostic criteria, there was low awareness of risk stratification tools. Coding was perceived as valuable for health professionals but not for patients. Concerns included increasing patient anxiety and over-medicalisation. Time pressures and lack of incentivisation were perceived as key barriers. Improved healthcare professional education, guidelines, pathways and technology/automation were highlighted as areas of potential improvement. Conclusion Primary care awareness of CKD is high, but workload, time pressures, and concerns regarding patient anxiety/over-medicalisation may contribute to incomplete risk stratification. Refining processes and effective patient communication could improve care.
General practice in the UK faces a growing retention crisis, with many experienced GPs reducing hours or leaving patient care amid rising workload and system strain. Understanding what sustains GP careers is crucial to stabilising the workforce. To explore how experienced GPs' career intentions have evolved since the 2016 ReGROUP study and to identify factors influencing decisions to stay, reduce, or leave clinical work. Qualitative interview study with experienced GPs in South West England, analysed using the Job Demands-Resources (JD-R) model. We conducted 19 semi-structured interviews with GPs who had previously completed the ReGROUP survey. Transcripts were analysed thematically with input from public and professional stakeholders. GPs described escalating clinical and administrative workloads, moral distress, and reduced control as key pressures driving burnout and exit. Hybrid access models, secondary care workload transfer, and punitive regulatory processes intensified strain. Retention was supported by clear workload boundaries, continuity of care, supportive practice systems, portfolio careers, and collective advocacy. Some GPs maintained engagement by reshaping their roles or practice structures to regain control and sustain meaning. Retention depends not only on reducing workload but on restoring the conditions that make being a 'good GP' feel possible, through continuity, manageable demand, and supportive organisational culture. Creating space for flexibility, autonomy, and role redesign may help sustain experienced GPs and strengthen workforce resilience.
Background Parents play a vital role in protecting their children from healthcare-associated harms, for example through mitigating safety incidents in general practice. Despite international calls encouraging family involvement in patient safety initiatives, parental perspectives are rarely embedded in the co-design of safety improvements. Aim To co-generate and prioritise ideas for improving paediatric safety in general practice with parents and key stakeholders, and to explore areas of agreement and disagreement between these groups. Design&setting A multi-method study combined qualitative methodology with quality improvement tools involving four parent workshops and one stakeholder workshop. Parents had experience of accessing general practice services with their children, and stakeholders included clinicians, managers, policy makers, primary care leaders and patient advocates. Method Parents(n=33) reviewed national-level safety incident data and used nominal group technique to generate ideas for change. Ideas were collated, refined and presented to key stakeholders(n=7), who assessed the potential doability and impact of each idea. Results Parents generated 16 ideas for change targeting communication, access to care records and results, and shared learning and development. Stakeholders prioritised seven ideas, including flexible appointments, a designated parent advocate and a campaign to support parents to speak up. Parents and stakeholders most strongly agreed on the need to proactively seek parent feedback and solutions. Conclusion Parents are willing and able to support healthcare teams with their patient safety efforts. Their ideas align with national priorities and offer actionable strategies for general practice teams to adopt or adapt to tailor safer paediatric care to their own populations.
Early detection of multiple sclerosis (MS) could improve patient outcomes. Changes in clinical activity before MS diagnosis may represent 'diagnostic windows' for earlier detection. To determine whether certain prescriptions are more common in patients with MS and examine prescription patterns prediagnosis in the UK. Case-control study using routinely collected primary care data. Patients in the case group had an MS diagnosis (2001-2022) and patients in the control group were matched by birth year. Multivariable conditional logistic regression adjusting for sex and socioeconomic status (SES) examined associations between MS diagnosis and prescriptions for anxiety/depression, migraine, lower urinary tract symptoms (LUTS), urinary tract infection (UTI) treatments, sleep disorder, gastrointestinal (GI) symptoms, and erectile dysfunction (ED) in the 0-2, 2-5, 5-10 years prediagnosis/match date. Poisson regression adjusting for age, sex, and SES estimated the inflection points in the case group at which the rate of prescriptions changed from baseline, identifying the start of diagnostic windows. In total, there were 9662 patients in the case group and 56 455 in the control group. Positive associations were found between seven prescriptions and MS diagnosis, with highest odds ratios (3-7 times) in the 2 years prediagnosis. In the all-prescription analysis, inflection points were identified for: GI (69-72 months, 95% confidence interval [CI] = 51 to 90), LUTS (69-72 months, 95% CI = 30 to 111), UTI (66-69 months, 95% CI = 45 to 90), migraine (63-66 months, 95% CI = 27 to 102), ED (60-63 months, 95% CI = 30 to 93), and anxiety/depression (9-12 months, 95% CI = 3 to 18). Prescriptions for symptoms of possible MS were more common in the case group than the control group up to 10 years prediagnosis. Prescription rates changed years prediagnosis, indicating potential opportunities for earlier detection, but broad CIs demonstrated uncertainty regarding diagnostic window duration.
Structured medication reviews were introduced in 2020 to address polypharmacy in patients most at risk of medicines-related harm. To evaluate the impact of SMRs on prescribing in primary care. Retrospective observational cohort study of electronic health records from patients aged ≥65 years, prescribed one or more medications and fulfilling the specific eligibility criteria for a SMR, registered at practices contributing data to the Oxford Clinical Informatics Digital Hub (ORCHID), between 1 st April 2020 and 30 th September 2022. The association between SMRs and prescription changes was examined by matching individuals who received an SMR to individuals who did not receive an SMR, according to age, sex and primary care practice using cumulative density sampling. Analyses were undertaken using adjusted logistic regression. Of 635,698 eligible patients, 82,285 (12.94%, 95% confidence interval [CI] 12.86%-13.02%) received at least one SMR during the study observation period. In those prescribed potentially inappropriate drug combinations prior to an SMR, between 12.5% and 40.0% were corrected up to three months later. In matched analyses, SMRs were most strongly associated with an increase in new prescriptions of ACE inhibitors (adjusted odds ratio [aOR] 1.56, 95%CI 1.35-1.81), statins (aOR 1.78, 95%CI 1.57-2.02), and antidepressants (aOR 1.45 95%CI 1.28-1.63). SMRs were also associated with stopping these drug classes in those previously prescribed treatment. SMRs were associated with starting new medications and stopping existing prescriptions compared to usual care. Further work is needed to understand if these changes improved patient outcome.
Most hospital admissions are older patients, who are more likely to be medically complex. Primary care risks after hospital discharge and readmission trajectories are relatively unexplored. To estimate the frequency and nature of errors and harms linked to discharge summary processing in general practice for patients aged ≥65 years and explore associations with readmission and healthcare utilisation from a novel primary care data source. Retrospective cohort study using electronic health records (EHRs) from seven purposively sampled general practices in the West Midlands, UK. We reviewed EHRs for 263 patients aged ≥65 years discharged between October 2022-2023. Outcomes included post-discharge healthcare utilisation and costs, frequency and type of discharge actions, error rates (failures to complete requested actions), harms (severity, attribution, preventability), and 90-day readmissions. Multivariable logistic regression identified predictors of errors, harms and readmission. 186/263 discharged patients (70.7%) accessed post-discharge care; with 47/263 patients 17.5% (95% CI: 13.7-23.0%) having related readmissions within 90 days. The 263 discharge summaries requested 551 actions; 21.3% were not completed, over half involving medications. 12.5% of patients experienced error, 4.4% experienced harm. Most harms were preventable and resulted in hospital readmission. Error/harm disproportionately affected patients with dementia or recorded carer. General practice needs to review their processes for responding to patient discharge information in order to improve patient safety post-discharge. Further research into tools to assist practice with transitions is warranted.
Funding shortfalls persist for practices in the most deprived areas, despite capitation formula adjustments. Did deprivation scores predict practice payment trends between 2018-19 and 2023-24? Multivariable analysis of English general practices (2018-19 to 2023-24), excluding practices with <750 patients or average payments >£500/patient, using published data. We fitted a quadratic mixed effects model, using cluster-robust standard errors. The outcome was log-transformed average NHS practice payments per patient (net of deductions/reimbursements). The fixed effects were time (categorical), the Index of Multiple Deprivation (IMD) score (higher score = greater deprivation), and seven covariates (geographical, population or organisational). The random effect was practices' random intercepts. Among 5,726 included practices (85.2% of England's total), median payments increased in nominal terms [8.6%] but decreased in real-terms [-12.6% (consumer price index), -9.0% (health inflation)]. The IMD-payment trend relationship was curvilinear, peaking at IMD 49.8 (1.4% above mean deprivation, IMD 23.2), declining to 0.6% higher at IMD 70. More positive payment trends were associated with the non-London regions, rurality, greater long-term conditions (LTCs) prevalence, and higher baseline payments; less positive trends with more under 16s, larger lists and Personal Medical Services contracts. In interaction models, rurality increased whilst higher LTCs decreased IMD's impact. Deprivation had a positive but diminishing association with payment trends as deprivation increased, moderated by geography and morbidity. Payment uplifts must match inflation. Funding formulas must better compensate for deprivation/morbidity, address the attenuated positive effect of deprivation in high-LTC practices and minimise geographical inequalities.
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Most women with ovarian cancer are diagnosed after developing symptoms. However, symptoms are often recorded as free text within Electronic Healthcare Records (EHRs) which is not readily accessible for research. To use EHRs to examine associations between coded and Large Language Model (LLM) extracted free text clinical features with ovarian cancer diagnosis. Population based case-control study using EHR and cancer registry data. Women attending primary care, outpatient and emergency clinics associated with the University of Washington. 136 ovarian cancer cases (diagnosed 2012-2019) were matched (age, clinic type) to 1360 controls. 12 months of pre-diagnosis coded and free-text data were extracted from EHRs. LLMs were tested on annotated notes, before extracting information on 17 pre-specified clinical features. Univariate conditional logistic regression analyses were used to identify clinical features associated with ovarian cancer. 14 clinical features were more commonly identified from free text using LLMs than from codes in both cases and controls. 14 features were significantly associated with ovarian cancer when using codes than LLM extracted data, but only 8 features were significant using codes alone. Using both coded and LLM extracted data, 11 features had OR's >2. 13 features were significantly associated when restricting analysis to early-stage (I-II) diagnosis. There is an identifiable ovarian cancer symptom signature within EHRs, with LLM-based NLP approaches enabling extraction of key non-coded symptom information. LLM's could support EHR-based research, while LLM-based Clinical Decision Support Tools may improve identification of patients with symptoms of possible cancer.
Background Prescribing patterns in primary care could demonstrate early clinical features of cancer and windows of opportunity for timely investigation. Aim Analyse primary care prescription patterns prior to a pancreatic cancer diagnosis. Design and Setting Retrospective cohort study using linked primary care and cancer registry data from patients diagnosed with pancreatic cancer in England between 2011-2018. Method Prescription records registered in the Clinical Practice Research Datalink were analysed in the five years pre-diagnosis. Eight categories of prescriptions which may be used to treat clinical features of pancreatic cancer were included (anti-emetics, anti-reflux medications, insulin, other hypoglycaemic agents, opioids, non-opioid analgesics, neuropathic analgesics and non-steroidal anti-inflammatories). Poisson regression was used to estimate the inflection points for increased prescribing above baseline. Results Among 12,990 patients, 669,287 prescriptions were analysed. Insulin was the least common prescription (7% patients), anti-reflux the most common (53% patients). Insulin prescribing increased 19 months pre-diagnosis (95% confidence interval [CI]=14.2-23.8), rising earlier in females (25 months; 95% CI=17.4-32.5) than males (11 months; 95% CI=5.8-16.2). Prescriptions for other hypoglycaemic agents increased 13 months (95% CI=7.7-18.5), anti-reflux and opioid analgesic prescribing 7 months (95% CI=5.4-8.6 and 4.4-9.6, respectively) and anti-emetics and non-opioid analgesics 5 months (95% CI=2.9-7.1 and 3.2-6.8, respectively) prior to diagnosis. Conclusion The early increase in insulin prescribing suggests tumour-induced type 3c diabetes, highlighting an opportunity for earlier diagnosis in a small proportion of patients. Opportunities for earlier diagnosis through investigation and referral also exist in patients prescribed anti-emetic, anti-reflux, and analgesic medications in primary care.