General practice placements are facing increasing pressure from global clinician shortages, rising workload and limited physical space. Meanwhile, medical school cohorts continue to expand to support the global clinician shortfall. This mismatch creates a growing bottleneck for authentic patient-based learning and has intensified interest in digital placement models of education. Livestreamed Clinical Experiences (LCEs) - real-time broadcast consultations between clinicians and patients - offer a potential way to extend access to clinical learning, increase exposure to diverse cases and enable participation by rural or underserved communities. However, despite growing interest, educators currently lack practical guidance on how to implement LCEs in general practice in ways that are ethically robust, technically feasible and pedagogically purposeful. Drawing from educator experience, literature and pilot data, we outline key practical considerations across five themes: planning and governance, technical setups, patient-centred consent, pedagogically purposeful delivery, and sustainable evaluation and scale-up. Our aim is to provide a concise, practice-oriented narrative reflecting what worked, what proved challenging and what may support others to implement effective LCEs. We include a practical implementation checklist and an LCE facilitation model to guide educators through the planning, ethical and technical stages of delivery.

BACKGROUND:Reducing health inequity is essential. The FAIRSTEPS (Framework to Address Inequities in pRimary care using STakEholder PerspectiveS) study developed and prioritised 28 vignettes describing complex primary care interventions targeted to disadvantaged groups, through Delphi consensus ranking by primary care practitioners for feasibility and perceived usefulness. AIM:To build on FAIRSTEPS by quantifying potential impacts of prioritised vignettes on cost-effectiveness and health equity. DESIGN & SETTING:Simplified distributional cost-effectiveness analysis (DCEA) in England. METHOD:Pragmatic literature searches were carried out around each vignette to identify the following: (1) available economic evidence; and (2) information about size and distribution of populations targeted. Economic evidence was quality assessed using adapted National Institute for Health and Care Excellence (NICE) appraisal checklists. Extracted cost and quality-adjusted life-year (QALY) data and population data, were combined with published distributions of health opportunity costs and baseline lifetime health, to estimate net health benefits and equity measures for each vignette. RESULTS:Suitable cost-effectiveness evidence was identified for 17 of 28 vignettes, with variable study quality and applicability. Fourteen vignettes were both cost-effective and equity-generating, with the most beneficial on both dimensions relating to community champions for health promotion; integrated care for people sleeping rough, engaged in sex work, or using drugs; and weight-loss programmes targeted at people on low incomes. CONCLUSION:Simplified DCEA using published data can be used to provide additional evidence to help prioritise complex primary care interventions aimed at disadvantaged populations, although the analysis is hindered by low quality economic data and limited study comparability. Further research estimating baseline health and health opportunity cost distributions across disadvantaged groups would improve accuracy of health equity assessments.

BACKGROUND:Dementia is projected to rise steepest in racially minoritised communities; nearly six times the UK average. Understanding of disparities is limited due to research under-representation, however evidence suggests racially minoritised people experience delayed diagnoses, more often in crisis situations, and die younger. AIM:To explore cultural understandings of ageing and dementia, and barriers/enablers to healthcare access for family-carers of racially minoritised people with memory problems. Generate community-led intervention ideas to improve access/uptake. DESIGN & SETTING:Scoping review of UK literature 2) Qualitative Photovoice (participatory action research) focus groups with family-carers of people with memory concerns from Chinese, Caribbean and South Asian communities in Sheffield 3) Co-design workshops with community leaders on intervention prototypes. METHOD:Scoping review of barriers/enablers and existing interventions. Photovoice methodology: purposive recruitment of 24 family-carers (8/community) supporting those aged≥65 with memory concerns; diverse in gender, age and language. Eight-week data collection culminating in focus groups co-facilitated and interpreted by bilingual community research link workers, transcribed verbatim, and independently thematically analysed. Photo-exhibition for public and policy-makers. Stakeholder workshop with community leaders to co-design intervention prototypes. CONCLUSION:Despite steeply rising dementia rates in racially minoritised communities, inequity persists in service access/uptake. Little is understood about cultural influences effecting engagement with dementia care and no formal intervention development tackling racial inequity has been published. This work will increase knowledge on cultural nuances and structural discrimination impacting families living with dementia and consider new approaches.

Objectives Health inequities are unjust and avoidable differences in health outcomes across populations and between population groups. Though these arise predominantly from social determinants of health, healthcare is estimated to contribute around 20 % and primary healthcare reduces inequities in healthcare outcomes. As each provider works in their local context, we sought to provide an evidence-informed framework for designing, implementing, and evaluating local health inequity interventions in primary care. Study design Mixed methods approach: an integrative evidence review, a multidisciplinary Delphi consensus study and collaborative patient and public participation. Methods We searched published and grey literature for examples of primary care health inequity interventions. Our Delphi survey then asked primary care professionals how feasible and useful similar interventions would be in their local contexts. We incorporated an ongoing dialogue people with lived experience of health inequity in our design, implementation, and analysis. Results Sixty-nine published papers and 19 grey literature papers were included. Interventions included multiple objectives (e.g., tailored provision, practitioner training) or focus (e.g., medical care, screening). Theory underpinning intervention design was rarely explicit but some specific tools and theory was identified for the framework. Practitioners and our patient group prioritised 28 example interventions to aid the design of local contextually sensitive interventions. Conclusions We combined evidence synthesis, practitioner consultation and dialogue with people with lived experience produced an evidence-informed framework for the design, implementation and evaluation of local primary care health inequity interventions. The public and practitioner voice increases the credibility of our framework as a useful tool for service development.

Background: UK general practice training requires trainees to evidence clinical competencies through reflective writing entries in online portfolios. Trainees who complete their medical degree in the UK experience reflection as an undergraduate, whereas 80% of international medical graduates (IMGs) have no previous experience of reflection. Aim: To explore IMGs' perspectives on the positive and negative aspects of reflection in the context of postgraduate GP training. Design & setting: A mixed- methods qualitative study undertaken in the UK. Qualitative 'free- text' survey data obtained in 2021 were analysed. The themes were further explored by semi- structured interviews conducted in 2022-2023. Method: Participants were IMGs with experience of the UK GP training scheme. Verbatim open- question survey data underwent content analysis. Broad themes identified were used to develop the interview topic guide. A geographically dispersed, purposive sample of participants were recruited for semi- structured interviews. Interview and survey data were then analysed thematically. Results: In total, 433 participant datasets are included: 422 of 485 responses to a UK- wide survey, including open questions, and 11 interview transcripts. IMGs considered reflection to provide an effective approach for learning, an opportunity for self- assessment and professional development, and a means of developing self- awareness. Concerns were expressed about how time- consuming recording reflection is, how its mandated aspect makes it forced, and fears regarding the medico- legal consequences of reflective writing. Conclusion: Despite a lack of previous experience in reflection, most IMGs showed an understanding of the benefits of reflection in GP training. However, the challenges of reflection must be addressed, to avoid devaluing reflection for clinical learning.

Background: General practice is an essential part of healthcare systems in the UK and internationally but continues to struggle with recruitment. Despite this, few studies have explored factors that influence medical students' career choices around primary care. Aim: We aimed to revisit factors that had previously been proposed following new ways of working adopted since the COVID- 19 pandemic, including the impact of these changes on learning experiences in primary care. Design & setting: A qualitative study using focus groups across three English medical schools. Method: Eight focus groups were held involving 33 final and penultimate year medical students. Qualitative data were analysed using a framework approach. Transcripts were coded independently by two researchers from a different institution before themes were identified. Results: Six themes were identified: students' prior career aspirations, their experience of the medical school curriculum, conceptualisation of general practice, future career predictions, views on the school's curriculum philosophy, and the influence of the COVID- 19 pandemic. The curriculum philosophy of each school appeared to be important in this journey and changes since the COVID- 19 pandemic had an impact on all themes. Conclusion: Our study has confirmed previous findings that clinical experiences, the perceived narrative of the school, work-life balance, and working environment remain important to students in making career plans. However, in addition, we have found the changing landscape in general practice since the COVID- 19 pandemic, including remote consulting, workload, continuity of care, and teamworking, are additional factors that concern students.

THE PROBLEMSocial inequalities are driven by power, income, and wealth, and shape health inequalities.The 'inverse care law' has enduring relevance to UK primary care.Underserved groups, including those living in poverty and those from ethnic minorities, spend more years with chronic conditions, have worse health outcomes, and poorer access to health care. 1 It is self-evident that clinical research should generate results that are generalisable to the whole population. 2 So why is 'inverse representation' in research the norm?The sociodemographic characteristics of participants in recent clinical trials suggest a mismatch with the representation of underserved populations, especially ethnic minorities. 3Inverse representation in research may be driven by discriminatory exclusion criteria that limit participation.This article focuses on researcher power, whereby researchers exercise control and influence inclusion in research, and suggests a theory-driven, empowering participatory approach to widen representation of underserved populations.Commissioners of research, universities, and organisations that support recruitment may have prioritised efficiency (easier recruitment and lower attrition) over rigour (generalisable, representative sampling) and likelihood of implementation in all settings.Incorporation of flawed clinical trial evidence into clinical guidelines could widen health inequalities by shifting resources towards those interventions that work in populations at the lowest risk of poor outcomes.The prevalence of type 2 diabetes mellitus (T2DM) is significantly higher in ethnic minority and socioeconomically deprived populations; however, research that underpins a group education intervention (DESMOND) for people with T2DM recruited mostly White British people (94%) and did not report deprivation data. 4Referral activity to group education sessions for people with T2DM is incentivised by the UK GP Quality and Outcomes Framework, but uptake of these sessions in areas of high socioeconomic deprivation and among ethnic minorities is poor. 5,6articipation in clinical research has benefits for patients; for example, cancer outcomes are better in patients who participate in clinical trials. 7Interestingly,

Background: Reflection is a key component of postgraduate training in general practice. International medical graduates (IMG) are thought to be less familiar with reflection, with international medical schools favouring more didactic methods of education. Aim: To explore IMGs' experiences of reflection prior to and during GP training and the support available for developing skills in reflection. Design & setting: A cross sectional survey was sent to IMGs undertaking GP training in 12 of the 14 UK regions, from March to April 2021. Method: A pre-tested self-administered online questionnaire was used to collect data on experiences of reflection, both prior to and during GP training, and the support available for developing skills in reflection. Results: In total, 485 of 3413 IMG trainees completed the questionnaire (14.2% response rate, representative of national demographics). Of these, 79.8% of participants reported no experience of reflection as an undergraduate and 36.9% reported no formal training in reflection during GP training. The majority (69.7%) of participants agreed that reflection was beneficial for their training and 58.3% reported that the best support in reflection came from their supervisors. Experience of reflection, opinions on the benefits, and best sources of support all varied by where the responders' primary medical qualification (PMQ) was obtained (all P values<0.01). Conclusion: Most IMGs have not experienced reflection prior to commencing UK GP training. There is diversity in experience and culture within this group that must be considered when tailoring educational interventions to support IMGs in their transition to UK GP training.

Purpose: Longitudinal Integrated Clerkships (LICs) are a recognised model of curriculum design used internationally as an alternative to traditional block rotations in medical schools that have been shown to offer a multitude of educational benefits. As a relatively new development in the United Kingdom (UK), it is not yet clear whether these benefits will translate into a UK healthcare context. This article provides an early review of evaluations of UK LIC programmes. Methods: A narrative literature review of LIC programme evaluations in UK medical schools. Results: UK students and faculty found value in the LIC programmes with reported benefits including continuity of relationships, increased responsibility and purpose for students, a patient-centred approach and development of professional skills. However, students and GP tutors expressed initial anxieties adapting to the newness of the programme design and preparedness for exams. Conclusions: UK LIC programmes appear to be offering benefits for UK medical students and faculty members including personal and professional development in line with international literature. However, the current data is limited with significant gaps that need addressing for the impacts to be fully realised.

Background Reflection is an essential tool for postgraduate medical training, yet fear of exposing incompetence is a known barrier for engagement with reflection. In the UK, this fear may have been amplified by the case of Dr Bawa-Garba, whose reflective e-portfolio entries informed a General Medical Council investigation resulting in the loss of her licence to practice. Aim To identify themes GP trainees commonly explore in e-portfolio entries, and whether their reflective e-portfolio entries have changed following the Bawa-Garba case. Method A phenomenological approach was applied. Semi-structured interviews continued to data saturation in a purposive sample of trainees (7) and trainers (4) recruited from a South Yorkshire GP training scheme. Transcript data were assigned to a coding framework with iterative thematic analysis. Results Dominant emergent themes were 'difficulty' and 'challenge'. All trainees described reluctance to submit significant event analyses (SEAs) on mistakes and near misses for fear of jeopardising their careers. International medical graduates were disproportionately affected by the challenges reflection posed. Conclusion Following the Bawa-Garba case, trainees are disengaging with SEAs to reduce the risk of self-incrimination. Further guidance with which trainees can navigate their reflective e-portfolios is required to retain the value of reflection as a tool for professional development.

Abstract Clinical reasoning remains a key area for development amongst clinical students across the world. Physician assistant (PA) roles (physician associate in the United Kingdom) are rapidly expanding, and there is a need to ensure that this core skill is reflected in course curricula. This article presents how the University of Sheffield has integrated clinical reasoning into the curriculum for its PA course. This includes recognizing the need to consider different approaches to reasoning and how they are taught, the assessment of reasoning across Miller's pyramid, and other considerations that contribute to embedding reasoning within the course. We discuss the implications of our approach and comment on issues that we may need to consider in the future.

The main factor sustaining any healthcare is the investment in the people that deliver care. Technology does not care for people, buildings do not care for people. People care for people. Inequities in workforce distribution contribute to inequities in access to healthcare. Such inequities matter to all of us, contributing to worsening health outcomes in mental health, obesity rates and overall life expectancy. We know that roughly 70% of NHS investment goes on workforce. How this gets spent matters. This chapter explores further: -Getting the workforce right. -Workforce capacity, capability and organisational resilience -The challenges and constraints at a time of workforce expansion. -Evidence from primary care. -How workforce inequality can affect different locations. -Solutions to workforce issues and how to apply them

Edited by Graham CM Watt CRC Press , 2018 , PB, 275 pp, £29.99 , 978-1785231582 In the introduction to his new book, Graham Watt likens its contents to a ‘tapas menu’, best sampled in different selections rather than as a series. In serving up this menu, Watt has provided something light and refreshing but not without sustenance. The book itself serves to keep the torch of general practice burning bright and strong. Rather than provide another overarching academic critique of the value of general practice (community-based primary medical care), Watt provides us with a more illuminating constellation of contributions from GPs at the frontline, academics, and other health professionals who are seeking, through a variety of methods, to …

The NHS is seriously under-doctored, with general practice being one of the worst-affected specialties. GPs are a highly trusted and valued profession by patients. In addition, the ‘gatekeeping’ function and continuity of care they provide is critical to the efficiency of the services as a whole, keeps hospital admissions down, and produces better healthcare outcomes for communities and populations. Major efforts are being made to recruit new GPs and retain existing GPs, but there are serious implications for the future of primary care, and general practice in particular, as GPs struggle to cope with increased workloads. Increasing the number of GPs in the workforce is critical, and this work continues as a priority. However, a parallel stream of work has developed to consider ways in which tasks ‘traditionally’ undertaken by a GP might be diverted to new healthcare professionals within primary care teams, freeing up GPs to concentrate on the care and management of their more complex patients.

Background GPs working in areas of high socioeconomic deprivation face particular challenges, and are at increased risk of professional burnout. Understanding how GPs working in such areas perceive professional resilience is important in order to recruit and retain a GP workforce in these areas. Aim To understand how GPs working in areas of high socioeconomic deprivation consider professional resilience. Design and setting A qualitative study of GPs practising in deprived areas within one primary care region of England. Method In total, 14 individual interviews and one focus group of eight participants were undertaken, with sampling to data saturation. A framework approach was used for data analysis. Results Participants described three key themes relating to resilience. First, resilience was seen as involving flexibility and adaptability. This involved making trade-offs in order to keep going, even if this was imperfect. Second, resilience was enacted through teams rather than through individual strength. Third, resilience required the integration of personal and professional values rather than keeping the two separate. This dynamic adaptive view, with an emphasis on the importance of individuals within teams rather than in isolation, contrasts with the discourse of resilience as a personal characteristic, which should be strengthened at the individual level. Conclusion Professional resilience is about more than individual strength. Policies to promote professional resilience, particularly in settings such as areas of high socioeconomic deprivation, must recognise the importance of flexibility, adaptability, working as teams, and successful integration between work and personal values.

Background GPs working in areas of high socioeconomic deprivation face particular challenges, and are at increased risk of professional burnout. Understanding how GPs working in such areas perceive professional resilience is important in order to recruit and retain a GP workforce in these areas. Aim To understand how GPs working in areas of high socioeconomic deprivation consider professional resilience. Design and setting A qualitative study of GPs practising in deprived areas within one primary care region of England. Method In total, 14 individual interviews and one focus group of eight participants were undertaken, with sampling to data saturation. A framework approach was used for data analysis. Results Participants described three key themes relating to resilience. First, resilience was seen as involving flexibility and adaptability. This involved making trade-offs in order to keep going, even if this was imperfect. Second, resilience was enacted through teams rather than through individual strength. Third, resilience required the integration of personal and professional values rather than keeping the two separate. This dynamic adaptive view, with an emphasis on the importance of individuals within teams rather than in isolation, contrasts with the discourse of resilience as a personal characteristic, which should be strengthened at the individual level. Conclusion Professional resilience is about more than individual strength. Policies to promote professional resilience, particularly in settings such as areas of high socioeconomic deprivation, must recognise the importance of flexibility, adaptability, working as teams, and successful integration between work and personal values.

Quality Improvement skills are deemed essential for future clinical practice of doctors by professional regulatory bodies. This paper presents the challenges of a curriculum development initiative to ensure that all medical students have involvement with a quality improvement project during a general practice placement in their fourth year. The curriculum development is described within a 'Plan-Do-Study-Act'framework.The learning is presented as a reflective discussion with conclusions and recommendations on how potential current barriers to implementing authentic participation in quality improvement projects for undergraduate medical students might be met.The key barriers include lack of opportunities within the curriculum structure to allow sufficient time for authentic quality improvement projects and a lack of confidence amongst placement tutors to support medical students with quality improvement projects.

Sustainability and Transformation Plans (STPs) have now been submitted for all 44 areas across England, swiftly followed by corresponding plans from clinical commissioning groups (CCGs) for how they intend to strengthen and transform health services across their communities. CCGs were required to outline how the investment described in the General Practice Forward View ( GPFV ) will be utilised to support general practice, to reverse some of the damage done by years of underinvestment, and create a position from which primary care can begin to strengthen.1 Stronger general practice is an imperative for the sustainability of STPs if the NHS is to function in a form recognisable from its founding principles.When people feel unwell, they look to the trusted places within their NHS. It is GP surgeries that have the expertise to provide comprehensive, generalist first-contact care, but when they are unable to meet demand people predictably seek help in accident and emergency (AE a place ill designed for their problems. On presenting to Au0026E, the likelihood of someone having a preventable admission is directly …