Background In the last decade, social prescribing through link workers based in general practice has become a major policy in the UK, but little is known about the implementation of this strategy. We aimed to explore the roles, challenges, and effects of social prescribing link workers (SPLWs) across different models of employment, organisation, and management in England and Scotland. Methods In this qualitative study, we conducted semi-structured interviews with stakeholders in two regions in England (National Institute for Health and care Research [NIHR] Applied Research Collaboration [ARC] West and NIHR ARC North East and North Cumbria) and two in Scotland (National Health Service [NHS] Greater Glasgow & Clyde and NHS Lothian). Stakeholders were participants actively involved in SPLW activities and comprised patients aged 18 years or older receiving SPLW support; individual SPLWs; general practice staff who referred patients to the SPLW; leads of voluntary, community, and social enterprises (VCSEs) employing or hosting SPLWs; VCSE leads not employing or hosting SPLWs but supporting referred patients; and strategic leaders working with SPLW services. Purposive sampling was used to ensure diversity in patients’ age, gender, and socioeconomic deprivation (according to the Index of Multiple Deprivation in England or Sottish Index of Multiple Deprivation in Scotland) and variation in stakeholder roles. Interviews were continued until data saturation was reached. Transcribed interviews were analysed reflexively using inductive thematic analysis. Findings Between Feb 16 and Nov 15, 2024, we conducted interviews with 130 stakeholders: 36 SPLWs, 28 patients, 28 referring professionals, ten VCSE leads hosting SPLWs, 14 VCSE leads not hosting SPLWs, and 14 strategic leads. Patient ages ranged from 18 years to older than 65 years; 16 (57%) patients were female, 12 (43%) were male, 26 (93%) were of White British or Scottish ethnicity, one (4%) was of south Asian ethnicity, and one (4%) was of mixed or multiple ethnicity. Six key themes emerged. The first was varied backgrounds, with SPLWs typically coming from the voluntary sector or NHS, driven by a desire to empower patients. The second was changing role, with SPLWs now seeing many more patients with highly complex needs, including the social determinants of health in deprived areas, than they did previously. The third theme was therapeutic relationship, whereby building empathic relationships was crucial but depended on SPLWs’ backgrounds, training, and support. The fourth theme, benefits of the SPLWs, was based on SPLWs helping patients to build confidence and increase their independence and, in general practitioners, reducing moral distress and possibly reducing workload. The fifth theme was employment models, organisation, and management, with integration into general practices facilitated by SPLWs working in one or two practices and with robust organisational support. For the final theme, challenges and sustainability, the challenges of the SPLW role included job retention, burnout, variable pay levels, and few opportunities for career progression; the sustainability of this role was threatened by short-term funding, increased service demand, and financial cuts to essential services. Interpretation This study highlights the vital role of SPLWs in England and Scotland and the need for stable support and funding amid ongoing financial challenges in the statutory and voluntary sectors. Funding National Institute for Health and Care Research.

Individuals experiencing homelessness face significant health inequalities. They are often met with stigma and exclusion in everyday life, including in health and social care settings. As a result of this marginalisation, homeless populations can be unfairly labelled as 'hard to reach' and misrepresented in research. Public health research increasingly aims to address health inequalities by engaging vulnerable and excluded groups in the research process. However, researchers lack specific guidance on navigating ethical and methodological issues when conducting research with the homeless community. This paper discusses practical barriers to including individuals experiencing homelessness in research. It then presents an emerging framework that discusses relevant literature, best practices from adapted frontline homelessness health and social care support, and perspectives from those with lived experiences of homelessness. We propose a flexible framework adaptable to different research methods and realistic conditions encountered when working with homeless participants. The framework employs a stepwise approach to research design, based on principles of equitable involvement, safeguarding vulnerable populations, and empowering those experiencing homelessness. Starting with research inputs, the framework recommends expert collaboration and contributions from individuals with lived experience. During the research, it suggests that researchers consider (1) practical exclusionary factors, (2) minimising distress and re-traumatisation risks, (3) open communication and rapport, (4) maintaining professional conduct, (5) strong community partnerships, (6) informed consent in context, (7) intersectionality and tailored approaches. It also encourages (10) community dissemination and (11) advocacy for individuals experiencing homelessness regarding research outputs. The framework highlights the ethical and methodological considerations researchers need to address when including individuals experiencing homelessness in their studies. It is a broadly accessible resource for qualitative researchers designing projects involving populations experiencing homelessness within health and social care research.

BACKGROUND:Social prescribing link workers (SPLWs) have been based in general practices in Scotland since 2016 but the views of GPs on their work have not been quantified. AIM:To quantify GPs' satisfaction with the work of SPLWs and belief that they can reduce health inequalities, and to explore GP and practice factors that influence these views. DESIGN & SETTING:Secondary analysis of a cross-sectional survey of all qualified GPs' working lives in Scotland conducted in 2023-2024. METHOD:Descriptive analysis of how satisfied GPs are with SPLWs, and whether they believe they can reduce health inequalities, and univariate and multivariate analysis of factors that influence these views. RESULTS:In total, n = 836/1380 (60.6%) of GPs reported having a SPLW in their practice, and of these, 567 (67.8%) were satisfied with their work, and 587 (70.2%) thought they could reduce health inequalities. In multilevel multiregression analysis, three significant independent positive predictors of GP satisfaction with the work of SPLWs were identified: female GP sex (P = 0.017), high practice deprivation (P = 0.001), and a perceived reduction in GP workload (P<0.001). GPs' belief that SPLWs can reduce health inequalities was predicted by high practice deprivation, and a perceived reduction in GP workload (both P<0.001). CONCLUSION:GPs in Scotland who have an SPLW in their practice are largely satisfied with link workers. GPs believe SPLWs can reduce health inequalities, especially those working in deprived areas and who perceive reductions in their own workload owing to the work of the SPLW.

BACKGROUND:Green social prescribing (GSP) aims to link patients to nature-based health interventions (NBHIs) through GPs. However, knowledge of GPs' views on GSP is limited. AIM:To explore GPs' views on GSP and the factors influencing these views. DESIGN & SETTING:National cross-sectional survey of GPs' working lives in Scotland, conducted in 2023, which included four questions about GSP. METHOD:Descriptive analysis of GPs' views of GSP and univariate and multivariate (binary logistic) analysis of factors influencing these views. RESULTS:The survey found 79.6% (n = 1098) of GPs had heard of GSP, 81.3% (n = 1106) would be happy to refer patients to NBHIs, 67.8% (n = 931) thought GSP was suitable for older patients with multimorbidity, and 43.7% (n = 599) felt that patients living in deprived areas would access GSP. Greater knowledge of GSP was associated with White ethnicity (adjusted odds ratio [aOR] 2.04; 95% confidence interval [CI] = 1.30 to 3.22, P = 0.002) and the number of clinical sessions worked per week (aOR 0.90; 95% CI = 0.82 to 0.99, P = 0.034). Higher job satisfaction was associated with more positive views about the suitability of GSP for older patients with multimorbidity (aOR 1.14; 95% CI = 1.00 to 1.30; P = 0.043) as were views on whether patients living in deprived areas would access GSP (aOR 1.20; 95% CI = 1.03 to 1.33, P = 0.013). GPs working in deprived areas also had more positive views regarding whether patients living in deprived areas would access GSP (aOR 1.24; 95% CI = 1.06 to 1.45, P = 0.159). CONCLUSION:GPs in Scotland are aware of and willing to refer to GSP but have concerns about accessibility for patients from deprived areas. Views were influenced by personal and practice characteristics.

BACKGROUND:Co-location and integration of services within a psychologically informed environment (PIE) is recommended for people experiencing homelessness (PEH) but there are few examples of this in the UK. Such a centre opened in Edinburgh, Scotland in November 2021. AIM:To evaluate progress of the new centre. DESIGN & SETTING:This was a mixed-methods pre-post-test design study before (baseline) and 2 years after (follow-up) the move to the new co-located centre. The study took place in Edinburgh, Scotland. The baseline evaluation was conducted at two separate homelessness services and the follow-up evaluation at the new co-located centre. METHOD:Baseline and follow-up staff surveys measured knowledge of trauma-informed care (TIC), wellbeing, team climate, and job satisfaction. The follow-up staff survey also evaluated staff support and service improvements. In-depth staff interviews were conducted at baseline (n = 25) and follow-up and analysed thematically. A service-user survey was also conducted. RESULTS:The staff survey showed significant improvements between baseline and follow-up in TIC, burnout, and team climate, together with improvements in support, service integration, and service-user care. Service users reported high satisfaction with the new centre. Staff interviews identified a more PIE, better staff support, and improved opportunistic multidisciplinary working over the 2 years of the centre opening. However, a number of barriers were also identified relating to the building and the IT systems. Further work on the centre's vision, short and long-term integration plans, workload, and sustainability were felt to be needed. CONCLUSION:Co-location of services for PEH in Scotland has led to reductions in staff burnout and improvements in team climate and service users' satisfaction over the first 2 years of opening. However, barriers remain and full integration requires a clearer vision and 'roadmap', requiring collaborative leadership and sustainable funding.

MMQ1 is a Danish-language patient-reported outcome measure (PROM) for quality of life (QOL) in people with multiple long-term conditions (MLTC). It measures needs-based QOL across six scales: Physical ability, Concerns and worries, Limitations in daily life, Social life, Personal finances and Self-image. There is currently no such measure available in English. This study aimed to translate and validate MMQ1 for use in the United Kingdom. Translation used a two-panel method (expert panel: n = 5; and lay panel: n = 6). Content validity was assessed via cognitive interviews (n = 6). A postal survey of 2,753 patients with MLTC recruited through eight GP practices in Scotland included EQ-5D-5L and ICE-CAP as comparator measures alongside MMQ1. Classical test theory psychometric analysis of survey responses followed the International Society for Quality of Life Research minimum reporting standards. Translation resulted in an English-language MMQ1 with good face validity. Cognitive interviews established good content validity. 597 survey responses were received (response rate 22

Social prescribing link workers (SPLWs) connect people to community resources for better health and well-being. Over the past decade, SPLW schemes have expanded rapidly in NHS primary care in England and Scotland. However, how these schemes have been implemented and assessed in different parts of England and Scotland is not well understood. A mapping exercise of SPLW schemes in three English and two Scottish regions was undertaken to identify services and describe their key features, as well as any variations in delivery, what data are recorded, and how outcomes are measured. Consultations were held with SPLW stakeholders (n = 98) supplemented with online analysis. Using the TIDieR framework, a taxonomy of SPLW services was created. Across the five regions, four different SPLW employment models were identified, varying by employer and SPLW management approaches. Some regions used up to three models, others only one. Local variations in delivering SPLW schemes included different referral routes, age ranges, priority groups, types of SPLW schemes available, and number of sessions offered. A variety of methods were used to assess service user outcomes, including validated well-being tools, bespoke well-being tools, bespoke service user surveys, and qualitative case studies. Variation existed in data recording systems used and, in the frequency, and consistency in using assessment tools and recording service user outcomes. Variation in SPLW delivery models indicates regional and localized interpretations of SPLW schemes. Variations in recording and measuring service user outcomes and in well-being tools used present challenges for effective evaluation/s of each model and primary care SPLW schemes overall. Enhancing local and national data systems, along with supporting strategies and frameworks for evaluations, would boost SPLW infrastructure and support future policy developments.

Backgroundolder people experiencing homelessness can have mental and physical indicators of aging several decades earlier than the general population and experience premature mortality due to age-related chronic conditions. Digital interventions could positively impact the health and well-being of homeless people. However, increased reliance on digital delivery may also perpetuate digital inequalities for socially excluded groups. The potential triple disadvantage of being older, homeless, and digitally excluded creates a uniquely problematic situation warranting further research. Few studies have synthesized available literature on digital interventions for older people experiencing homelessness. ObjectiveThis scoping review examined the use, range, and nature of digital interventions available to older people experiencing homelessness and organizations supporting them. MethodsThe scoping review followed Arksey and O’Malley’s proposed methodology, PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, and recent Joanna Briggs Institute guidelines. We searched 14 databases. Gray literature sources were searched to supplement the electronic database search. A narrative synthesis approach was conducted on the included articles, and common themes were identified inductively through thematic analysis. ResultsA total of 19,915 records were identified through database and gray literature searching. We identified 10 articles reporting on digital interventions that had a clearly defined a participant age group of >50 years or a mean participant age of >50 years. A total of 9 of 10 studies were published in the United States. The study design included descriptive studies, uncontrolled pilot studies, and pilot randomized controlled trials. No studies aimed to deliver an intervention exclusively to older people experiencing homelessness or organizations that supported them. Four types of intervention were identified: telecare for people experiencing homelessness, distributing technology to enable digital inclusion, text message reminders, and interventions delivered digitally. Interventions delivered digitally included smoking cessation support, vocational training, physical activity promotion, and cognitive behavioral therapy. Overall, the included studies demonstrated evidence for the acceptability and feasibility of digital interventions for older people experiencing homelessness, and all 10 studies reported some improvements in digital inclusion or enhanced engagement among participants. However, several barriers to digital interventions were identified, particularly aspects related to digital inclusion, such as infrastructure, digital literacy, and age. Proposed facilitators for digital interventions included organizational and peer support. ConclusionsOur findings highlight a paucity of evaluated digital interventions targeted at older people experiencing homelessness. However, the included studies demonstrated evidence of the acceptability and feasibility of digital interventions for older people experiencing homelessness. Further research on digital interventions that provide services and support older people experiencing homelessness is required. Future interventions must address the barriers older people experiencing homelessness face when accessing digital technology with the input of those with lived experience of homelessness. Trial RegistrationOSF Registries OSF.IO/7QGTY; https://doi.org/10.17605/OSF.IO/7QGTY

BackgroundHomelessness staff often experience high job demands, limited resources, and significant emotional strains; with high levels of burnout, stress, and trauma being common within the workforce. Despite growing recognition of these issues, limited literature exists on interventions to address them. This study aims to conduct a systematic scoping review to map and identify interventions aimed at improving well-being and reducing burnout among homelessness staff.MethodsAll eligible studies needed to include an intervention addressing burnout and/or well-being in homelessness staff, published in English with primary data. Evidence sources were left open with no data restrictions. Following protocol registration, a systematic search of five electronic databases (Medline, APA PsychInfo, Global Health, ASSIA, CINAHL) and Google Scholar was conducted. Studies were double-screened for inclusion. Methodological quality was assessed using the Mixed Methods Appraisal Tool.ResultsOf the 5,775 screened studies, six met the inclusion criteria: two peer-reviewed and four non-peer-reviewed publications. No studies were retrieved from Google Scholar. The included studies comprised four quantitative non-randomised designs, one randomised controlled trial, and one mixed-methods study. All included studies were complex interventions. Three were therapy-based, two included supervision, and two were one-time educational sessions. Most were conducted in the United States (n = 4), with two in the United Kingdom. The total pooled sample was 347 participants, though four studies were missing demographic data (age and gender). The studies used heterogenous measures and outcomes. Limitations included restrictions to English-only publications, potential gaps in capturing well-being measures, and a limited grey literature scope.ConclusionThere is a lack of research on well-being and burnout interventions in frontline homelessness staff. Identified studies were generally low quality, using heterogenous measures and outcomes to assess well-being and burnout, limiting the generalisability of findings. Future research should employ more robust study designs with standardised measures and outcomes.

BackgroundScotland has the widest health inequalities in western Europe and a well-documented inverse care law in general practice. Scotland introduced a new General Practitioner contract in 2018, reforming how care is delivered. Changes included expanding the primary care multidisciplinary team, and grouping practices into geographical clusters to improve quality of care for the local populations. A stated aim of the new contract was also to reduce inequalities in health. However, the effects of the reforms upon health inequalities have been little explored. This study aimed to analyse the views of General Practitioners working in deprived areas on the impact of the contract on health inequalities in Scotland.MethodsThis study involved a secondary analysis of qualitative data from one-to-one interviews with 11 GPs serving patients in deprived areas of Scotland. Thematic analysis was used to analyse the data.ResultsDespite some positive opinions on some aspects of the contract, GPs in deprived areas felt that the aim of reducing inequalities had not been achieved. Reasons for this were: (1) persisting barriers to engagement for patients in deprived areas (including poor access to services, lack of patient education about the reforms, centralisation of some services, and difficulties with remote consulting), (2) inadequate support to manage patients with complex problems (including difficulty in providing continuity of care, and limited resources for patients with specific comorbidities such as mental health and chronic pain), (3) clusters in areas of deprivation lacking capacity to address health inequalities (including lack of time, lack of training, and lack of data and evaluation), and (4) a lack of workforce and strategic planning in the new contract regarding deprivation (such as suitable resource allocation and recruitment of sufficient numbers of appropriate staff in practices in deprived areas). Two additional cross-cutting themes were identified, relating to lack of time and poor relationships.ConclusionsThe new Scottish General Practice contract has not achieved its aim of reducing health inequalities, according to General Practitioners working in deprived areas. Future iterations of the contract need to implement changes that will tackle the inverse care law and thus help reduce inequalities in health.

OBJECTIVE:To systematically review the one and three year impact on quality of care of the introduction and withdrawal of financial incentives in the UK Quality and Outcomes Framework pay-for-performance programme. DESIGN:Systematic review with quantitative synthesis. DATA SOURCES:MEDLINE, Embase, CINAHL, PsycINFO, and Scopus databases were searched from 1 January 2004 to 3 September 2024. STUDY SELECTION:Eligible studies used repeated cross sectional or cohort designs with consistent measurement before and after incentive introduction or withdrawal. Studies with a minimum of three time points before and after intervention were included in quantitative synthesis. DATA EXTRACTION:Analysis used both reported impact if available and de novo interrupted time series analysis of extracted raw data if not reported by the original study. DATA SYNTHESIS:Meta-analysis was not appropriate; findings were quantitatively synthesised by reporting medians and interquartile ranges of changes in quality or reported narratively. Risk of bias was assessed using the Mixed Methods Assessment Tool. RESULTS:30 studies were included, with 11 providing data for quantitative synthesis. Across all indicators, evidence was found of improvement in recorded quality at one year after incentive introduction (83 indicators; median change compared with that predicted by pre-incentivisation trends 6.1 (interquartile range (IQR) 1.9 to 14.6) percentage points) but less consistently at three years (72 indicators; median change 0.7 (-2.1 to 8.9) percentage points). Impact was higher for process indicators with lower performance in the year before incentivisation. Incentive withdrawal was associated with reduction in recorded quality compared with predicted at both one year (31 indicators; median change -10.7 (IQR -17.9 to -3.8) percentage points) and three years (31 indicators; median change -12.8 (-21.0 to -4.4) percentage points). The largest changes with both incentive introduction and withdrawal were for complex process indicators such as diabetes foot screening, with smaller changes in simple processes such as blood pressure measurement, intermediate outcomes, and treatment indicators. For all types of indicators, the reduction in quality following incentive withdrawal generally matched or exceeded the gains observed after incentive introduction (for example, for 14 indicators with data for both, median change at three years for incentive introduction was a 1.4 (IQR -0.9 to 4.6) percentage point increase versus a 3.9 (IQR 2.2 to 11.6) decrease for incentive withdrawal). CONCLUSION:Quality and Outcomes Framework incentives consistently improved quality of care at one year beyond that predicted by pre-incentivisation trends, but by three years the impact was inconsistent and not clearly better than trend. Gains from incentivisation seemed to reverse after incentive withdrawal. STUDY REGISTRATION:Prospero CRD42023467627.

Introduction: Social prescribing seeks to connect people to community‐based resources, to improve their health and wellbeing. It is often framed as a response to health inequalities. However, the impact of place‐based differences is seldom considered. As social prescribing depends on local resources, this is a significant knowledge gap. This review aims to examine the extent to which social prescribing research to date has engaged with places and communities. Methods: This state‐of‐the‐art literature review has three components: (1) Four databases (PubMed, ASSIA, Web of Science and Scopus) were searched for social prescribing literature reviews; key characteristics were charted and a timeline created. (2) Each review was assessed for its engagement with concepts of place, and findings were synthesised narratively. (3) Exploratory searches were conducted in PubMed for primary research on place in social prescribing, and findings summarised descriptively. Results: A total of 97 eligible literature reviews were identified. A timeline of these reviews and their characteristics was created, including population, referral reasons, social prescribing model, intervention and aim. No reviews had ‘complete’ engagement with concepts of place. Thirty‐one had ‘partial’ engagement. These suggested five ways of thinking about place: place as healing, experience of societal inequalities and its effect on place, how deprivation shapes place, place as the context for social prescribing and alternative conceptions of place. We found eight primary studies addressing social prescribing and place. Six looked in detail at a particular place or characteristic of places, and two contributed theoretical understandings of the relationship between place and social prescribing. Discussion: The role of place in social prescribing remains understudied. Future research could develop theory and frameworks to account for place or identify which elements of place‐based community infrastructure are particularly relevant for social prescribing, especially as deprivation and austerity continue to diminish community resources in the areas which most need them.

BACKGROUND:The Scottish Government introduced the first phase of a new General Practice (GP) contract in 2018, aiming to transform primary care and address health inequalities. However, the impact of these changes on patient satisfaction is unclear. AIM:To assess temporal changes in overall patient satisfaction, and satisfaction with access and consultation quality, in general practice between 2011/12 and 2021/22, focusing on disparities across sociodemographic groups. DESIGN AND SETTING:Analysis of biennial national Health and Care Experience (HACE) survey data from patients in Scotland, spanning six survey waves. METHODS:Descriptive analyses of trends in patient satisfaction, access, and consultation quality. Disparities in deprivation were measured by the Relative Index of Inequality (RII). RESULTS:Overall patient satisfaction with general practice declined significantly over the 10 years, with mean positive scores dropping from 90.1% in 2011/12 to 70.5% in 2021/22. Satisfaction was lower in patients living in more deprived areas at all time points, and the gap between the most and least deprived populations widened over time, with the RII increasing from 1.05 (95% CI 1.04-1.06) in 2011/12 to 1.12 (95% CI 1.08-1.15) in 2021/22. Overall satisfaction and access satisfaction had the most pronounced declines, especially among younger patients and those with multiple long-term conditions. In contrast, consultation quality measures (whether patients felt listened to and had enough time during consultations) remained largely stable with only slight declines observed. CONCLUSION:Satisfaction overall, and with access to GP consultations, steadily declined between 2011/12 and 2021/22, with a more pronounced decrease following the COVID-19 pandemic, particularly among the most deprived and complex patients. Although the new GP contract was introduced during this period, it does not appear to have significantly impacted these downward trends. These findings highlight the need for focused efforts to improve patient satisfaction, especially in disadvantaged populations, as the contract evolves.

BACKGROUND:The 2018 Scottish GP contract established GP Clusters and multidisciplinary team (MDT) expansion. Qualitative studies have suggested suboptimal progress with these initiatives. AIM:To quantify progress since the introduction of the new contract. DESIGN & SETTING:A cross-sectional postal survey of all qualified GPs was undertaken in Scotland in 2023. METHOD:GPs working lives, career intentions, and views on the new contract were compared with a similar survey conducted in 2018. RESULTS:In total, 1385/4529 (31%) GPs responded to the 2023 survey compared with 2465/4371 (56%) in 2018. Job satisfaction and negative job attributes were similar in both surveys. Both positive job attributes (P = 0.011) and job pressures (P = 0.004) increased but the changes were small (effect sizes <0.2). Significantly more GPs were planning to reduce hours (P<0.001) and leave direct patient care (P = 0.008) in 2023 than in 2018. Quality leads' views on Cluster working were unchanged, with 70-80% reporting insufficient support. Cluster knowledge and engagement was unchanged but there were small increases in knowledge of quality improvement. More than half of the GPs reported that access to MDT staff was insufficient to reduce their workload in all staff categories except vaccinations. Significantly more practices were trying to recruit GPs (P<0.01), and GPs reported worsening NHS services, higher workload, and lower practice sustainability in 2023 (P<0.001). Only 5% of GPs in the 2023 survey thought that the new contract had improved the care of patients with complex needs. CONCLUSIONS:GPs report few improvements in working life 5 years after the new contract was introduced, and are responding by planning to reduce their hours or leave direct patient care.

Background The new Scottish GP contract commenced in April 2018 with a stated aim of mitigating health inequalities. Aim To determine the health characteristics and experiences of patients consulting GPs in deprived urban (DU), affluent urban (AU), and remote and rural (RR) areas of Scotland. Design and setting In 2022, a postal survey of a random sample of adult patients from 12 practices who had consulted a GP within the previous 30 days was undertaken. Method Patient characteristics and consultation experiences in the three areas (DU, AU, RR) were evaluated using validated measures including the Consultation and Relational Empathy (CARE) Measure and Patient Enablement Instrument (PEI). Results In total, 1053 responses were received. In DU areas, multimorbidity was more common (78% versus 58% AU versus 68% RR, P<0.01), complex presentations (where the consultation addressed both psychosocial and physical problems) were more likely (16% versus 10% AU versus 11% RR, P<0.05), and more consultations were conducted by telephone (42% versus 31% AU versus 31% RR, P<0.01). Patients in DU areas reported lower satisfaction (82% DU completely, very, or fairly satisfied versus 90% AU versus 86% RR, P<0.01), lower perceived GP empathy (mean CARE score 38.9 versus 42.1 AU versus 40.1 RR, P<0.05), lower enablement (mean PEI score 2.6 versus 3.2 AU versus 2.8 RR, P<0.01), and less symptom improvement (P<0.01) than those in AU or RR areas. Face-to-face consultations were associated with significantly higher satisfaction, enablement, and perceived GP empathy than telephone consultations in RR areas (all P<0.05). Conclusion Four years after the start of the new GP contract in Scotland, patients' experiences of GP consultations suggest that the inverse care law persists.

BACKGROUND:Expanding primary care multidisciplinary teams (MDTs) was a key component of the 2018 Scottish GP contract, with more than 4700 MDT staff appointed since then. AIM:To explore patients' views on primary care MDT expansion in Scotland. DESIGN & SETTING:A mixed-methods evaluation, which included a postal survey and semi-structured telephone interviews with patients in Scotland. METHOD:A survey was undertaken of patients who had recently consulted a GP in deprived urban, affluent urban, and remote and rural areas, assessing awareness of five MDT roles and attitudes towards receptionist signposting. In addition, 30 individual interviews were conducted, exploring patients' MDT-care experiences. RESULTS:Of 1053 survey responders, most were unaware of the option of MDT rather than GP consultations for three out of five roles (69% unaware of link worker appointments; 69% mental health nurse; and 58% pharmacist). Reception signposting was less popular in deprived urban areas (34% unhappy versus 29% in remote and rural versus 21% affluent urban; P<0.001), and in patients with multimorbidity (31% unhappy versus 24% in non-multimorbid; P<0.05). Just over two-thirds of interviewees had multimorbidity and almost all reported positive MDT-care experiences. However, MDT care was generally seen as a supplement rather than a substitute for GP care. Around half of patients expressed concerns about reception signposting. These patients were more likely to also express concerns about GP access in general. Both of these concerns were more common in deprived urban areas than in remote and rural or affluent urban areas. CONCLUSION:MDT care has expanded in Scotland with limited patient awareness. Although patients understand its potential value, many are unhappy with reception signposting to first-contact MDT care, especially those in deprived urban areas living with multimorbidity. This represents a barrier to the aims of the new GP contract.

Background Primary care transformation in Scotland aims to improve population health, reduce health inequalities, and reduce GP workload. Two key strategies (formalised in April 2018 in the new Scottish GP contract [Scottish General Medical Services contract], although started in early 2016) are the expansion of the multidisciplinary team (MDT) and GP cluster working. Aim To explore progress in the implementation of the GP contract in Scotland in terms of the MDT and cluster working. Design and setting Qualitative study with key national primary care stakeholders (PCSs) (n = 6) and cluster quality leads (CQLs) in clusters serving urban high deprivation areas (n = 4), urban mixed areas (n = 4), and remote and rural areas (n = 4). Method Semi-structured interviews with thematic analysis. Results There was general support for the initial aims of the new GP contract but all interviewees felt that progress on both MDT expansion and cluster working was slow, even before the pandemic. None of the CQLs (and few PCSs) felt that GP workload had reduced significantly, nor that the care of patients with complex needs had improved. Lack of time and poorly developed relationships were key barriers, as was a lack of relevant primary care data, and additional support (including guidance, administration, training, and protected time). Conclusion Key PCSs and CQLs in different areas of Scotland report limited progress in primary care transformation, only partly related to the pandemic. There is a need for better workforce planning and support if the new GP contract is to succeed in transforming primary care in Scotland.

There is uncertainty about how best to diagnose asthma, especially in primary care where mis-diagnosis is common. To address this, we developed a clinical decision support system (CDSS) for asthma diagnosis in children and young people (aged 5-25 years). This study explored the feasibility and acceptability of the CDSS in UK primary care. We recruited general practices from England and Scotland. The CDSS was available for use during routine consultations for six months. We analysed CDSS usage and, toward the end of the study, undertook qualitative interviews with clinicians who had used the CDSS. Within the 10 practices who completed the study, the CDSS was used by 75 out of 94 clinicians. 11 clinicians from 8 practices were interviewed. The CDSS was acceptable to participants who particularly commented on the ease of use and auto-population of information from the patient record. Barriers to use included the inability to record findings directly into the patient notes and a sense that, whilst possibly useful for trainees and junior colleagues, the CDSS would not necessarily lead to a change in their own practice. The CDSS was generally well received by primary care clinicians, though participants felt it would be most useful for trainees and less experienced colleagues.

ObjectiveAsthma can be difficult to diagnose in primary care. Clinical decision support systems (CDSS) can assist clinicians when making diagnostic decisions, but the perspectives of intended users need to be incorporated into the software if the CDSS is to be clinically useful. Therefore, we aimed to understand health professional views on the value of an asthma diagnosis CDSS and the barriers and facilitators for use in UK primary care.MethodsWe recruited doctors and nurses working in UK primary care who had experience of assessing respiratory symptoms and diagnosing asthma. Qualitative interviews were used to explore clinicians' experiences of making a diagnosis of asthma and understand views on a CDSS to support asthma diagnosis. Interviews were audio-recorded, transcribed verbatim and analyzed thematically.Results16 clinicians (nine doctors, seven nurses) including 13 participants with over 10 years experience, contributed interviews. Participants saw the potential for a CDSS to support asthma diagnosis in primary care by structuring consultations, identifying relevant information from health records, and having visuals to communicate findings to patients. Being evidence based, regularly updated, integrated with software, quick and easy to use were considered important for a CDSS to be successfully implemented. Experienced clinicians were unsure a CDSS would help their routine practice, particularly in straightforward diagnostic scenarios, but thought a CDSS would be useful for trainees or less experienced colleagues.ConclusionsTo be adopted into clinical practice, clinicians were clear that a CDSS must be validated, integrated with existing software, and quick and easy to use.

ABSTRACT Scotland has an ageing population and the widest health inequalities in Western Europe. Multiple health conditions develop ∼10–15 years earlier in deprived areas than in affluent areas. General practice is central to the effective and safe management of such complex multiple health conditions, but the inverse care law has permeated deprived communities ('Deep End' general practices) for the past 50 years. A new, radical, Scottish GP contract was introduced in April 2018, which has a vision to improve quality of care through cluster working and expansion of the multidisciplinary team (MDT), enabling GPs to deliver 'expert generalism' to patients with complex needs. It states a specific intention to address health inequalities and also to support the integration of health and social care. Here, we discuss recent evidence for whether the ambition of the new GP contract, to reduce health inequalities, is being achieved.