Background General practice (family medicine) experiences more violence and abuse by patients and the public than in general hospital settings. Qualitative accounts on how violence and abuse are experienced and perceived remain limited in both breadth and depth. Aim To explore direct and indirect experiences of violence and abuse that general practice staff have encountered from patients and the public, and the perceived impact on staff wellbeing and their practice. Design and setting This qualitative study was the second part of a mixed-methods project, following an online nationwide survey of England. 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 include a wide range of behaviours. It has profound and, in some instances, longstanding impacts on staff, including a persistent sense of being unsafe and disruption to their personal or social lives. It also affects clinical services through staff turnover and reduced service capacity.
Background Accurate risk stratification of patients with chest pain in primary care may improve patient safety while reducing unnecessary hospital referrals. Aim To evaluate the diagnostic performance of a clinical decision rule (CDR) combining high-sensitivity tro-ponin I (hs-cTnI) and the Marburg Heart Score (MHS) to rule out acute coronary syndrome (ACS), and specifically myocardial infarction (MI), in primary care patients with chest pain, and to compare referral rates with usual care. Design and setting Cluster-randomised diagnostic trial (2:1 intervention:control) conducted in Dutch primary care practices. Method Patients presenting with acute chest pain were assessed using a CDR applied by general practitioners, combining the MHS with a hs-cTnI point-of-care test. General practitioners in the control group provided usual care. Diagnostic performance was evaluated using sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). Secondary endpoints included evaluation of a modified HEART score and single hs-cTnI rule-out strategy. Results In total, 827 participants were included: 740 intervention and 87 controls. The CDR missed one ACS, yielding a sensitivity of 98.3% (95% CI 90.8-100%) and NPV of 99.7% (95% CI 98.0-100%). Specificity was 49.1% (95% CI 45.3-52.9%) and PPV 14.1% (95% CI 13.2-15.1%). For MI, sensitivity and NPV were both 100% (95% CI 92.6-100% and 95% CI 98.9-100%, respectively). Specificity was 48.6% (95% CI 44.8-52.4%), and PPV 11.9% (95% CI 11.1-12.7%). Referral rates did not differ significantly between groups (54.6% vs 47.1%; p=0.39). Conclusion A CDR combining the MHS with a hs-cTnI point-of-care test safely ruled out ACS and MI in(..)
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.
