Background High-quality primary care can improve multimorbidity management but little evidence is available to understand its impact on secondary care use over time. Aim To assess the concurrent and lagged associations between quality of primary care and planned and unplanned secondary care use, examining the modifying role of frailty. Design and Setting A retrospective cohort study included 468,172 patients with multimorbidity in England from the Discover research platform (April 2022-March 2024). Method We used principal component analysis to combine a set of quality indicators (QIs) and assessed the impacts of QIs on both planned and unplanned care using regression models. Results Generally, patients with higher QI attainment also had higher likelihood of outpatient visits, emergency admissions and ED visits. There was a lower lagged odds of elective hospital admissions in the following 12 months among those with higher attainment of multimorbidity-specific QIs. In the complex multimorbidity cohort (≥3 conditions), multimorbidity-specific QIs were longitudinally associated with lower odds of elective admissions and outpatient visits, while generic QIs were related to lower odds of outpatient non-attendance. Conclusion Attainment of generic and multimorbidity QIs was generally associated with slightly increased planned and unplanned care. However, patients for whom we identified higher attainment of multimorbidity-specific QIs had lower odds of elective admissions and outpatient visits, especially for those with complex multimorbidity. Our research suggests that the quality of primary care may influence patients' use of secondary care, with the potential to improve care for people with multimorbidity and warrant further investigation into management strategies.
Suicide is a major public health concern, and general practice is often a recent point of contact before death. While mental illness is well recognised, the broader social and contextual factors influencing suicide risk remain under-reported in primary care and epidemiological research Aim To describe the demographic, clinical, and psychosocial characteristics of individuals who died by suicide, integrating coronial quantitative data with qualitative narrative accounts to identify implications for primary/ secondary care and public health. Design and setting Explanatory sequential mixed‑methods study of 157 consecutive deaths by suicide recorded by coroners (2018-19) across five English local authorities. Method Demographic, clinical, and social data were extracted from coroners' records and summarised descriptively. Narrative case summaries were coded and analysed thematically to identify contextual, relational, and service factors preceding death. Results Of 157 individuals: 79% were male; 65% lived in the most deprived IMD quintile; 85% had a diagnosed mental health condition; 62% had a long‑term physical illness; 41% had a previous suicide attempt. About half consulted a GP in the preceding three months; mental health featured in about half of those consultations. Common stressors were relationship breakdown (37.2%), housing instability (22.1%), and work pressures (18.2%). Seven interlinked themes were identified: Mental health; Alcohol/Substance use, Physical health; Social connectedness; Life course trauma, Socioeconomic and Structural Vulnerability; Healthcare access. Service transitions were key vulnerability points Conclusion Coroners' records offer important insights into the complex circumstances preceding suicide and highlight opportunities for GPs to recognise intersectional complexity and support integrated, cross-sector suicide prevention approaches.
BACKGROUND:Chronic pelvic pain (CPP) affects an estimated 14.8% of UK women. Survivors of sexual violence are more likely to experience CPP, but the relationship is complex and underexplored. Shame and stigma from both experiences may interact and influence help-seeking. AIMS:To broaden understanding of how women survivors of sexual violence make personal meaning of CPP, and to consider clinical implications of findings. DESIGN & SETTING:A qualitative study of UK community-recruited women who have survived sexual violence and who experience chronic pelvic pain (CPP). METHOD:Ten participants were recruited via social media and engaged in individual, semi-structured online interviews about their experiences and understandings of sexual violence and CPP. Interviews were transcribed verbatim and analysed using reflexive Thematic Analysis. RESULTS:Three main themes were developed: (1) Healthcare professionals' attempts to silence women, who felt ignored, disbelieved or dismissed; (2) Treating the whole woman, describing the need for integrated, biopsychosocial approaches; and (3) A woman's place is in the resistance, highlighting women's active efforts to reclaim their narratives and pursue care. Shame was compounded across experiences, and women expressed frustration with fragmented care and assumptions about the psychological origins of pain. CONCLUSIONS:These results give insights into the complex meanings women survivors of sexual violence hold about their CPP, and how healthcare systems could better support them to explore and respond to those meanings. The aim should be compassionate care that recognises the complex biopsychosocial impact of sexual violence and CPP, while keeping women in control of their own care.
Background Primary care is the main route to diagnosis for patients with prostate cancer, either following asymptomatic Prostate Specific Antigen (PSA) testing or investigating prostate-related symptoms. Whilst previous primary care studies suggest an association between symptoms and prostate cancer diagnosis, it remains unknown whether outcomes differ based on the presence or absence of symptoms. Aim To compare prostate cancer stage, grade, and mortality amongst symptomatic patients presenting to primary care with asymptomatic patients. Design and setting Retrospective cohort study using Clinical Practice Research Datalink (CPRD) Aurum. Included adult males aged 50 years and above with first presentation to primary care for coded lower urinary tract symptoms (LUTS), haematuria, or erectile dysfunction between 01/01/2011 and 31/12/2016 with up to two asymptomatic males matched by age, ethnicity, and GP practice. Method Main outcomes: Clinically significant prostate cancer (Gleason Grade Group ≥ 3); Early-stage prostate cancer; Cambridge Prognostic Group; prostate cancer mortality; all-cause mortality. Mixed effect logistic regression modelling was performed. Results 722,597 males were included (262,178 [36.3%] had coded symptoms). Mean age was 64.4 years (SD 9.76). 90.68% identified as White ethnicity. 12,297 new prostate cancer diagnoses within 24 months of index consultation (8,101 [65.88%] in symptomatic group). Clinically significant prostate cancer (Adjusted OR 1.14 95% CI 1.07, 1.23) was more likely in the symptomatic group. No difference was found in stage at diagnosis (aOR 1.02 95% CI 0.95,1.09). Conclusion Investigating symptomatic patients in primary care is more likely to detect clinically significant prostate cancer with no difference in stage at diagnosis.
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: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. AIM:To explore practitioners views on discussing online activity and its role in the mental health of young people in primary care. DESIGN AND SETTING:Qualitative study with practitioners in GP and Talking Therapy Method: Semi-structured interviews with 24 practitioners, analysed using reflexive thematic analysis. RESULTS: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. CONCLUSION: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.
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: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. METHODS: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. RESULTS: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. CONCLUSION:These findings highlight key areas for change to foster a more inclusive and equitable research environment in primary care.
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.
BACKGROUND: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. AIMS: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. DESIGN AND SETTING: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. METHOD: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. RESULTS: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. CONCLUSION: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: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. AIM:To evaluate implementation of a named GP model and explain differences in implementation outcomes between two Finnish primary care units. DESIGN AND SETTING: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. METHODS: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. RESULTS: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. CONCLUSION: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:People with intellectual disabilities (referred to as learning disabilities in the UK) 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 years. AIM:To examine recent trends in learning disability registers and the uptake of learning disability annual health checks in England. DESIGN AND SETTING:Secondary analysis of publicly available general practice data. METHOD:NHS England data relating to the learning disabilities annual health check scheme from January 2022 to November 2025 were compiled and analysed. RESULTS:The number of 14-17-year-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% (n = 374 763/63 766 671) of patients are on learning disability registers, with approximately 0.526% (n = 355 102/63 654 156) aged ≥14 years and eligible for annual health checks. The uptake of annual health checks increased slightly from 68.08% (n = 15 940/23 414) to 71.58% (n = 19 217/26 846) among 14-17-year-olds, and from 79.07% (n = 226 701/286 714) to 80.71% (n = 248 449/307 827) among adults. Uptake was lowest in the South West and East of England, and highest in London, but was similar across deciles of patient deprivation and practice size. CONCLUSION:Ascertainment of people with a learning disability by primary care services appears to be improving but remains between one-third and one-quarter of prevalence estimates. The uptake of annual health checks among 14-17-year-olds continues to lag behind that of adults.
BACKGROUND:Learning disability registers in UK primary care support proactive care, but under-identification remains substantial. The 2019 NHS Long Term Plan introduced targets to increase enrolment. AIM:To estimate prevalence and rates of new registration to learning disability registers among young people aged 14-24 years in England and examine changes following the introduction of national targets. DESIGN AND SETTING:Population-based open cohort study using routinely collected primary care data from general practices in England contributing to the Clinical Practice Research Datalink Aurum database, 2015-2023. METHOD:Young people aged 14-24 years who had been registered ≥6 months were included. Annual rates of new registration per 10 000 person-years at risk (PYAR) and recorded prevalence were calculated, stratified by age, sex, region, and year. RESULTS:Between 2015 and 2023, 11 776 young people were first recorded on a learning disability register. Rates of new registration increased in 2020-2021 across ages and sexes, peaking at 15.8 per 10 000 PYAR in males aged 14-17 years and 8.4 per 10 000 in females before returning to pre-2019 levels by 2023. Recorded prevalence remained low overall (0.03-0.5%; 3.6-52.7 per 10 000) but increased among those aged 18-24 years, with eight-to-10-fold rises between 2015 and 2023. Prevalence was higher in males (rate ratios 1.7-1.8, 95% confidence interval = 1.6 to 1.9). CONCLUSION:National targets coincided with a temporary rise in enrolment, but identification remains below expected prevalence. Sustained policy focus and systematic identification and coding by practices are needed to ensure equitable access to preventive care during the transition to adulthood.
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.
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.
Background: Existing research on recurrent vulvovaginal thrush primarily frames experiences through the lens of acute, episodic, and one-off cases. Studies are lacking which investigate the implications of embedding recurrent cases into acute frameworks. This paper explores how a condition that is usually seen as one-off transitions into something for patients and healthcare professionals to think about and act on as needing longer-term care. Aim: To understand patient and clinician perspectives on seeking and providing care for recurrent vulvovaginal thrush, and how these insights might improve healthcare experiences. Design and Setting: Qualitative study of patient experiences with recurrent vulvovaginal thrush, and healthcare professional perspectives about providing care. Method: Interviews with 32 patients and 25 healthcare professionals working in primary care and sexual health services in England. Data were analysed using reflexive thematic analysis. Patient and public involvement informed study development and interpretation of results. Results: Patients and healthcare professionals agreed that acute, transient, and one-off cases of thrush could be self-managed effectively through pharmacy care. When thrush returned, persisted, or evolved, care needed to transition to a different approach, plan, and/or pathway was needed, however, integrating acute episodes could be complex. The themes highlight areas where the needs of people with recurrent vulvovaginal thrush diverged from acute cases, in terms of: (1) navigating disjointed health services, (2) recognising and responding to recurrence, (3) building ongoing healthcare relationships. Conclusion: Recurrent vulvovaginal thrush can be managed effectively in primary care, but requires approaches attentive to transitions, collaboration, and recognition of accumulative experiences.
