British Journal of General Practice最新文献

Background: Many patients receive routine medications for long-term conditions (LTCs). Doctors typically issue repeat prescriptions in one to three month durations, but England currently has no national guidance on the optimal duration.

Aim: Describe current prescription durations for common LTCs in England, explore and visualise geographical variation, and identify practice factors associated with shorter prescribing duration to inform policy making. Design and Setting A retrospective cohort study of English GP prescribing data December 2018-November 2019 Methods: We calculated the duration of prescriptions for common LTCs in England including the medications ramipril, atorvastatin, simvastatin, levothyroxine and amlodipine . We assessed the level of variation between regional clinical commissioning groups (CCGs) and determined practice factors associated with different durations.

Results: Of the common medications included, 28-day (one-monthly) prescriptions accounted for 48.5% (2.5 billion) tablets/capsules issued, whilst 43.6% were issued for 56 days (two monthly). There was very wide regional variation in the proportion of 28-day prescriptions (7.2% to 95.0%). Practice dispensing status was the most likely predictor of prescription duration. The proportion of patients with LTCs and the electronic health record software used by a practice were also associated with prescription duration.

Conclusions: One month prescription durations are common for patients taking medicines routinely for long term conditions, particularly in dispensing practices. Electronic health record configurations offer an opportunity to implement and evaluate new policies on repeat prescription duration in England.

Background: The challenges of recruiting and retaining rural GPs are well described. UK data suggest high levels of burnout, characterised by detachment, exhaustion, and cynicism, plays a role in GP turnover. The contrast is engagement with work. There is limited evidence examining the relationship between work engagement and recruitment and retention in rural areas.

Aim: To qualitatively investigate GPs decisions to move or stay in rural areas through exploring areas that can promote work engagement.

Design and setting: This was a secondary analysis of qualitative data with Scottish GPs.

Method: A secondary analysis of 44 semi-structured interviews with GPs from across Scotland was undertaken. Data were analysed thematically and the Areas of Worklife Scale was used to structure data.

Results: Factors associated with burnout were identified and experienced as barriers to moving or staying rurally. Fear of dealing with pre-hospital emergency cases, clinical isolation, and rural training were concerns. Personal factors such as lack of partner employment played a key role in migration decisions. Factors associated with engagement were identified and experienced as facilitators for moving or staying rurally. Professional networks reduced professional isolation and rural GPs valued increased autonomy and time. Many felt being a rural GP was more aligned with their professional values and highly valued the rural lifestyle for themselves and their families.

Conclusion: Our data suggest that factors associated with engagement and burnout can contribute to rural GPs' migration decisions. We highlight four areas that could promote desirable work environments by mitigating burnout and promoting engagement at work.

Background: General practice faces pressures because of increased demand and a shortage of GPs. Paramedics in general practice (PGPs) increasingly contribute to managing minor illnesses, conducting home visits, and providing urgent consultations.

Aim: To explore the impact of paramedic consultations on patient-reported experience, safe management, and NHS costs.

Design and setting: Prospective cohort study comparing PGP with GP consultations at 34 GP sites in England.

Method: Eligible participants had a consultation with a PGP (25 PGP sites) or GP (nine non-PGP sites) between May 2022 and February 2023. Questionnaires were provided after the initial consultation and 30 days later. Questionnaires assessed patient experience, outcomes, and perceived safety (PCOQ and PREOS PC), quality of life (EQ-5D-5L), and healthcare use.

Results: Of 715 participants recruited, 489 completed the 30-day questionnaire. No evidence was found that PGP consultations resulted in greater improvement/deterioration in patient-reported health and wellbeing (-0.03, 95% confidence interval [CI] = -0.09 to 0.04); confidence in health provision (-0.05, 95% CI = -0.15 to 0.05); health knowledge (0.05, 95% CI = -0.04 to 0.15); or confidence in the health plan (-0.06, 95% CI = -0.11 to -0.01) over the 30-day period. However, the PGP group reported lower confidence in health provision (mean 4.0 versus 4.5; P<0.001), poorer perceptions of practice engagement in safety promotion (median 75 versus 88; P<0.001), and more communication problems with staff (17% versus 8%; P<0.001) immediately after the initial consultation. Patients receiving PGP consultations reported fewer GP appointments during the 30-day period; however, savings to the NHS were offset by higher use of other healthcare professionals.

Conclusion: Well-designed training and supervision are needed to ensure PGPs have the right knowledge and can clearly convey healthcare plans to patients. While PGPs may reduce GP workload pressure, they do not necessarily reduce NHS costs.

Background: Modern general practice is characterised by increased demand and growing multidisciplinarity, including ring-fenced funding for additional non-clinical roles. For practice receptionists, however, training has remained unchanged for decades despite primary care being under greater pressure than ever, with receptionists becoming a growing focal point for abuse and unprecedented numbers leaving the role.

Aim: To present the evidence of the range of tasks that receptionists continue to perform, describing their impact on primary care delivery and how the role might be better supported.

Design and setting: Systematic review of research conducted in the UK.

Method: A systematic review of evidence contained in the major medical databases (MEDLINE/PubMed, CINAHL, ASSIA, Cochrane Library, and Embase) from January 2000 to March 2024 was conducted, including hand searches of the bibliographies of included studies.

Results: In total, 29 studies were identified that grouped into three themes: service delivery, patient attitudes, and receptionist experience. The theme 'service delivery' confirms the continuing role of receptionists in providing administrative support alongside the clinical tasks of prioritising patients for consultations, facilitating repeat prescriptions, and communicating blood test results. The theme 'patient attitudes' describes how patients lacked trust in receptionists, who were viewed as unqualified and unnecessarily obstructive. Finally, in considering receptionist experience, the contrast between their confidence in performing administrative roles and the anxiety induced from the clinically related tasks was described, particularly the mounting pressure from patients to meet their preferences for clinician appointments.

Conclusion: Although confident performing administrative tasks, receptionists described uncertainty and anxiety when providing clinically oriented support or managing patients when their requests for appointments could not be met. More appropriate training or professionalisation might improve staff retainment.

Background: Clinical guidance recommends promoting physical activity during general practice consultations. The frequency and content of physical activity discussions in UK general practice are poorly understood.

Aim: To explore the content of physical activity discussions during routine consultations between patients and GPs.

Design and setting: Secondary analysis was undertaken of video-recorded UK general practice consultations from the One in a Million study, which was conducted in the West of England.

Method: In total, 294 consultation transcripts were available; these were screened to identify consultations that included or omitted physical activity advice when recommended by National Institute for Health and Care Excellence guidance. The content, quality, and depth of advice provided by GPs were scored to ascertain how meaningful the advice was.

Results: Physical activity was relevant to management according to clinical guidance in 175/294 (59.5%) consultations. In 64 (36.6%) of these consultations, physical activity was discussed as part of clinical management; the depth of discussion was judged as 'meaningful' in 22 (12.6%) consultations. Although physical activity advice tended to be given most often for musculoskeletal problems, depth of advice did not appear to be related to the presenting problem. When physical activity advice was relevant and omitted, consultations prioritised another overriding presenting problem, or clinical management focused on another intervention.

Conclusion: Physical activity advice, following national guidance, was potentially relevant to more than half of GP consultations; GPs delivered advice of varying depth in a third of these consultations. Future work should explore ways of delivering physical activity advice effectively, efficiently, and equitably within the constraints of general practice.

Background: The introduction of remote and digital forms of working in UK general practice has driven the development of new routines and working styles.

Aim: To explore and theorise how new forms of work have affected general practice staff.

Design and setting: Multi-sited, qualitative case study in UK general practice.

Method: Using longitudinal ethnography by researchers in residence, we followed 12 practices for 28 months (September 2021 to December 2023). This core dataset was supplemented by workshops and stakeholder interviews. Data analysis applied theories from the sociology of work, organisation studies, and internet studies.

Results: Staff made significant efforts to adapt to and embed digital services into their work. When technologies work well they can offer improved convenience, efficiency, more comprehensive patient care, and workplace fulfilment for staff. However, for many clinical and administrative staff, compromises and frictions embedded in digitalised workplace routines and processes could also lead to job dissatisfaction, worsened wellbeing, and misalignments with professional values and identities. We found that this workplace suffering caused relational strain between team members and had an impact on team cohesiveness and coordination.

Conclusion: The digitalisation of working routines in UK general practice poses a unique challenge to the workforce, risking technostress, workplace suffering, and increased relational strain within and between teams. To embed the benefits of digitalisation, we must first improve practice teams' readiness for change, which includes strengthening practices' relational structures that provide support during periods of adaptation. Practices must be empowered to determine a locally appropriate configuration of digital tools and given the resources and time to adapt working routines.

Background: Social prescribing connects patients to resources or activities to meet their non-medical needs. In the UK, it is often implemented in primary care. In the social prescribing pathway, patients are directed to link workers to identify suitable solutions for their needs such as art workshops or welfare benefit guidance. Social prescribing marks a notable transition from traditional medical treatments to more comprehensive strategies focusing on holistic health and wellbeing. Insights from patient experiences can improve the development of social prescribing to better meet their needs. This understanding can aid in improving the delivery and outcomes of social prescribing.

Aim: To synthesise qualitative research on the experiences of social prescribing among patients in the UK.

Design and setting: Qualitative systematic review using thematic synthesis for peer-reviewed studies that focused on experiences of users of social prescribing in the UK.

Method: An exhaustive search was performed in six databases: ASSIA, CINAHL, Embase, MEDLINE, PsycINFO, and Social Sciences Citation Index via Web of Science. The Critical Appraisal Skills Programme tool for qualitative research was used for quality assessment and the PRISMA 2020 checklist was used to ensure the report transparency.

Results: Titles and abstracts of 1269 studies were screened. In total, 85 studies were full-text screened, and 19 studies were included in the review. Five analytical themes were developed from these studies: a) searching for hope in times of adversity; b) variability in temporal responsiveness; c) sustained change from a positive response; d) feeling supported and empowered by the social prescribing pathway; and e) misalignment producing no response.

Conclusion: Patients might experience lasting advantages from social prescribing if it aligns with their needs and expectations. Results highlighted the importance of matching social prescribing referral with patients' readiness to engage. Therefore, it is recommended that healthcare professionals evaluate patient suitability before beginning a social prescribing referral.

Background: The Additional Roles Reimbursement Scheme (ARRS) was introduced in England in 2019 to alleviate workforce pressures in general practice by funding additional staff such as clinical pharmacists, paramedics, first-contact physiotherapists, and from 1 October 2024 the scheme funds recently qualified GPs. However, the employment and deployment models of ARRS staff present ongoing complexities and challenges that require further exploration.

Aim: To explore the decision-making processes behind primary care networks (PCNs) and general practice staffing choices, and how these choices influence the operationalisation of ARRS.

Design and setting: This was a qualitative case study across four PCNs in England using a realist evaluation framework.

Method: Data collection took place between September 2022 and November 2023. Semi-structured interviews were conducted with PCN clinical directors, GPs, practice managers, and ARRS staff (n = 42). Transcripts were analysed using a realist evaluation framework to identify the context-mechanism-outcome configurations.

Results: Direct employment models fostered staff development and retention, contingent on established trust among practices. Subcontracting was favoured to mitigate employment risks but could lead to unintended consequences such as conflicting accountabilities and less integration with existing GP practice staff. The optimal deployment model involved rotations across a limited number of GP practices, ideally two, with one serving as a base, ensuring consistency in training and management.

Conclusion: This study provides novel insights into the complexities of different employment and deployment models of ARRS staff. These findings will be invaluable for creating a sustainable GP practice workforce and informing future workforce strategies as the scheme expands to include recently qualified GPs.

Background: Following the 2019 NHS Long Term Plan, link workers have been employed across primary care in England to deliver social prescribing.

Aim: To understand and explain how the link worker role is being implemented in primary care in England.

Design and setting: This was a realist evaluation undertaken in England, focusing on link workers based in primary care.

Method: The study used focused ethnographies around seven link workers from different parts of England. As part of this, we interviewed 61 patients and 93 professionals from health care and the voluntary, community, and social enterprise sector. We reinterviewed 41 patients, seven link workers, and a link worker manager 9-12 months after their first interview.

Results: We developed four concepts from the codes developed during the project on the topic around how link workers are integrated (or not) within primary care: (or not) within primary care: centralising or diffusing power; forging an identity in general practice; demonstrating effect; and building a facilitative infrastructure. These concepts informed the development of a programme theory around a continuum of integration of link workers into primary care - from being 'bolted on' to existing provision, without much consideration, to 'fitting in', shaping what is delivered to be accommodating, through to 'belonging', whereby they are accepted as a legitimate source of support, making a valued contribution to patients' broader wellbeing.

Conclusion: Social prescribing was introduced into primary care to promote greater attention to the full range of factors affecting patients' health and wellbeing, beyond biomedicine. For that to happen, our analysis highlights the need for a whole-system approach to defining, delivering, and maintaining this new part of practice.

Background: Workload is probably the biggest challenge facing general practice and little is known about any modifiable factors. For GPs, both continuity and locum status are associated with differences in outcomes.

Aim: To determine whether practice and hospital workload after an index acute consultation depend on the type of GP consulted (locums and practice GPs with [regular] and without [non-regular] continuity, and locums).

Design and setting: An observational, cross-sectional analysis of consultation-level data from English general practices from the Clinical Practice Research Datalink from 2015 to 2017.

Method: Antibiotic prescription was used as a marker for acute consultations with regression models to calculate adjusted relative risks for emergency department consultations and admissions, outpatient referrals, and test ordering, as well as the patients' GP reconsultation interval following consultations with the three types of GP.

Results: After adjustment, consultations with antibiotic prescriptions with regular GPs with continuity were associated with fewer subsequent hospital admissions and lower emergency department use but higher outpatient referrals relative to locums and non-regular GPs. Locums ordered tests less often (relative risk [RR] -24.3%, 95% confidence interval [CI] = -27.3 to -21.2) than regular GPs whereas non-regular GPs ordered tests more often (RR 19.1%, 95% CI = = 16.4 to 21.8). Patients seeing their regular GP had on average a 9% longer (95% CI = 8 to 10) reconsultation interval than if they saw any other GP.

Conclusion: The differences in outcomes were associated more with having continuity than with GP locum status. Seeing a GP with whom the patient had continuity of care was associated with reduced workload within the practice and in hospital.