British Journal of General Practice最新文献

Background: General practice has a key role in reducing inequity in access to care relating to sexual and reproductive health (SRH). Unplanned pregnancy, abortion, and sexually transmitted infections are increasing and disproportionately affect deprived communities and minoritised ethnic groups. The Candidacy Framework is a practical and theoretical framework for understanding the complex interactional processes of access to SRH care in general practice.

Aim: To use the Candidacy Framework to explore access to SRH care in general practice. The seven interaction stages are: identification of need; navigation of services; permeability of services; appearing and asserting need; adjudication by healthcare professional (HCP); offers or resistance of offer; and the local operating conditions or local production of candidacy.

Design & setting: Systematic review with qualitative evidence synthesis using a framework approach.

Method: A systematic search of MEDLINE, Embase, PubMed, and the Web of Science was conducted to identify primary qualitative research exploring access to SRH care in general practice from practitioner, public, and patient perspectives in countries with universal health care. The Candidacy Framework was used to synthesise the findings.

Results: Analysis of 42 studies revealed the impact of stigma, shame, and embarrassment among individuals, communities, and HCPs. Findings showed limited inclusion of demographics, such as ethnicity and socioeconomic status. Barriers to access were more evident for those from lower socioeconomic communities, minoritised ethnic groups, and the LGBTQ+ community. There are multiple barriers, which include the behaviours of HCPs, who have a crucial role in recognising an individual's SRH need.

Conclusion: General practice offers a cradle-to-grave healthcare service that should have SRH as a priority area of provision. Further understanding is needed about the impact of historic harms by medicine and health care on racialised individuals and minoritised genders.

Background: Identification of rheumatoid arthritis (RA) in primary care is challenging and often delayed. Anticyclic citrullinated peptide (anti-CCP) antibody testing of people presenting to primary care with new-onset musculoskeletal symptoms without synovitis could help address this; those testing positive are at increased risk of developing RA.

Aim: To explore how primary care clinicians currently identify and refer patients with suspected RA, and the behaviours required to implement a prediction model for guiding targeted anti-CCP testing for non-specific musculoskeletal symptoms in primary care.

Design and setting: A qualitative descriptive study in primary care in England.

Method: Eight GPs and eight musculoskeletal First Contact Practitioners (physiotherapists) participated in semi-structured interviews to explore their experiences of identifying and/or referring patients with suspected RA, and their views of a implementation package for the anti-CCP prediction model. Data were analysed using framework analysis.

Results: Variations in practice were evident across the pathway for identifying and/or referring patients with suspected RA, including in access to and use of the anti-CCP test. Implementing the anti-CCP prediction model would require clinicians to believe its benefits outweigh its risks, engagement of primary and secondary care teams, and incorporation of the prediction model within an easily accessible and useable clinical-decision support system. Participants' views about implementing the anti-CCP prediction model varied but were mostly positive overall.

Conclusion: Implementing a prediction model to guide targeted anti-CCP testing in primary care could be feasible. Further research is required to explore the potential benefits, risks, and costs of a pathway for identifying and/or managing people at risk of RA.

Background: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder that can have poor long-term outcomes when unmanaged. Young people aged 16-25 years with ADHD are often unable to access specialist health care as recommended by UK guidelines because of gaps in services, poor transitional support between child and adult services, and long waiting lists. Healthcare information, which is important for condition management, may help mitigate service gaps and support thriving in people with ADHD; however, little is known about provision via primary care.

Aim: To investigate experiences of information provision supporting management of young people with ADHD in general practice and explore the potential of digital resources.

Design and setting: This qualitative study comprised interviews with young people with ADHD, their supporters, and primary healthcare professionals from sites across England.

Method: Participants were recruited from five purposively sampled general practices, varying by local area characteristics. Semi-structured interviews included questions about information provision, healthcare information needs, and digital resources. Themes were generated using reflexive thematic analysis, within a critical realist framework.

Results: In total, 20 participants were recruited (11 healthcare professionals and nine people with lived experience). Four themes were generated: lack of ADHD-specific resources, supporting patients with condition management, dedicated resources for clinicians, and digital resources enhancing care. CONCLUSION: People with lived experience and healthcare professionals want better healthcare information about ADHD in general practice, including co-produced resources to support understanding and self-management. Digital resources represent a potentially cost-effective and accessible solution that is currently underutilised.

Background: Continuity of care is crucial for effective health care, but patients often experience discontinuity of care. Understanding the patterns and associated patient characteristics can guide interventions to improve continuity of care.

Aim: To investigate longitudinal provider discontinuity of care to identify disparities in patient characteristics across degrees of discontinuity of care in Danish general practice.

Design & setting: Cohort study using data from all Danish general practice patients aged ≥12 years, who were alive between 2007 and 2018.

Method: Logistic regression was employed to estimate discontinuity of care at level 0 versus: 1-2 shifts, 3-4 shifts, 5-6 shifts, 7-8 shifts, and ≥9 shifts. Five regression models were used to analyse the odds of different levels of discontinuity of care relative to demographic, regional, municipal, socioeconomic, and morbidity factors.

Results: The majority of males were likely to have lower levels of discontinuity of care than females; however, males in the subgroup with the most shifts had a higher likelihood of experiencing the highest level of discontinuity. Younger adults aged 25-44 years had a higher likelihood of moderate-to-high discontinuity of care compared to those aged 12-24 years, whereas older adults had a lower probability. Discontinuity of care was higher among residents of the Capital and Zealand Regions, and varied by municipality type - being lowest in intermediate areas and highest in peripheral and rural municipalities at the most severe levels. Individuals who were unemployed, those in the lower income quartiles, and those classified as being of 'other ethnicities' and single status had increased probability of discontinuity of care. Patients with lower or moderate-to-high morbidity were also more likely to experience discontinuity of care than patients with no chronic diseases.

Conclusion: This study revealed disparities in discontinuity of care linked to lower socioeconomic status and higher morbidity, with varying odds by region, municipality type, age, and gender.

Background: Recent evidence demonstrates persistence of the inverse care law (ICL) in general practice in England. Although the ICL was well-described in Scotland 20 years ago, progress in interventions since then is unclear.

Aim: To review national and local interventions that aimed to specifically address the ICL in Scottish general practice since 2000.

Design and setting: This was a systematic scoping review set in Scotland.

Method: Embase, Web of Science, PubMed, CINAHL, Cochrane and BASE from 2000 to February 2024 were searched. A systematic grey literature search of government, NHS and third-sector websites was also performed. All papers were double screened for inclusion. Both quantitative and qualitative studies were included and quality was assessed using the Joanna Briggs Institute tools.

Results: Out of 13 089 results, 67 papers reporting on 20 interventions were included. Interventions to improve general practice in deprived areas were categorised as: (a) enhancing patients' financial or social support, (b) targeting specific health conditions, (c) targeting specific groups, and (d) enhancing generalist health care. Six interventions accounted for 66% (44/67) of all included papers. Only two interventions have been rolled out nationally - community link workers and welfare advice and health partnerships - with both facing uncertain long-term funding.

Conclusion: There remains a major implementation gap between Scottish Government's policy ambitions to address health inequalities and sustainable delivery on the ground. To address the ICL, greater overall investment in general practice is needed, together with additional resources for more deprived areas according to local population need (a 'proportionate universalism' approach).

Background: Personal continuity is a hallmark for GPs but there is insufficient evidence to support its benefits in ordinary primary care populations.

Aim: To investigate the effects of GP personal continuity on the healthcare outcomes of primary care populations.

Design and setting: Systematic review of quantitative studies investigating associations between personal continuity of care and outcomes such as mortality and healthcare utilisation.

Method: Embase, PubMed, Scopus, and Web of Science were searched for studies published between 1 January 2000 and 31 October 2023. Owing to study heterogeneity the synthesis was conducted narratively; study results were summarised and expressed as having higher (compared with lower) continuity of care. Certainty of each summarised result was assessed using the GRADE framework.

Results: Out of 5792 unique references, 18 studies were included in the final analyses. The outcomes were grouped into three categories of summarised outcomes. Higher (when compared with lower) personal continuity with a GP/family physician probably prevents premature mortality (moderate certainty: four studies, 5 638 305 participants), probably reduces the risk of admission to hospital (moderate certainty: 11 studies, 13 642 684 participants), and probably lowers risk of emergency department visits (moderate certainty: seven studies, 3 855 487 participants).

Conclusion: Higher, compared with lower, continuity in the relationship between GP and patients in primary care populations is associated with reduced mortality, admissions to hospital, and emergency department visits. Relatively small improvements in personal continuity, which may be achieved in most practices, significantly reduce healthcare consumption, and thus may have an impact on access to care, which has implications for healthcare policy.

Background: In response to increasing demand for appointments, UK general practices have adopted a range of appointment systems. These systems vary widely in implementation. These changes have not yet been clearly described.

Aim: To characterise patterns of primary care delivery in English general practices.

Design and setting: Cross-sectional study using NHS Appointments in General Practice data from 3480 English GP practices, totalling 56 million appointments between August and October 2023.

Method: Twelve measures associated with consultation modality, waiting time, clinician type, and triage use were derived. Practices with similar characteristics for those 12 variables were clustered together using an ensemble machine learning approach. Clustering was validated using December 2023 data. The characteristics of each practice grouping were described using 2021 Census and NHS workforce data.

Results: Two main models of care emerged. 'Routine care' practices (n = 2286) tended towards face-to-face appointments, often delivered by non-GPs with longer wait times. 'Same-day care' (n = 1194) practices, a third of practices, were more likely to use telephone consultations, deliver care with GPs, and provide same-day appointments. Compared with 'routine care' practices, 'same-day care' practices were more likely to be in urban areas, had younger populations (mean age 40 years versus 41 years) and employed fewer patient-facing staff in extended roles (all clinical staff except doctors and nurses) (2.0 versus 2.5 full-time equivalents per 10 000 patients registered).

Conclusion: This study identified two dominant models of primary care delivery in England, reflecting differing approaches to managing patient access. These differences could have an impact on continuity of care and equity of access to primary care.

Background: Better continuity in primary and secondary care is linked to improved health outcomes, but it is unclear whether the sociodemographic determinants of continuity are the same in both settings and whether continuity measures in each setting are associated.

Aim: To examine the determinants of relational continuity in general practice and fragmented outpatient specialty care in people with clusters of multiple long-term conditions (LTCs) and the association between continuity in each setting.

Design & setting: A cohort of patients aged ≥18 years registered to general practices in England throughout 2019 and who had linked hospital outpatient records. Patients with ≥2 of 212 LTCs and with ≥3 general practice and ≥3 outpatient appointments were included.

Method: The Continuity of Care Index (COCI) was calculated separately for visits to the same a) GP and b) outpatient specialty, and associations calculated for sociodemographic factors and number of LTCs with COCI scores. The association was also assessed between indices in each setting using univariable and multivariable fractional logit regression.

Results: Of 1 135 903 patients, 56.3% (n = 639 489)were aged ≥60 years. Age was the strongest determinant of continuity in general practice, whereas number of LTCs was the strongest determinant in secondary care. Although statistically significant (P<0.001), the relationship between the COCI in general practice and outpatients was clinically insignificant in both univariable and multivariable models.

Conclusion: A lack of strong association between continuity of care in general practice and outpatient settings was found. This suggests that fragmented hospital care is not mitigated by increased continuity in general practice.

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: Access to general practice is a topical concern, with rising numbers of consultations and decreasing numbers of GPs placing strain on the service. Patient satisfaction with general practice has seen a reduction in the UK. While patient experience with general practice is well understood, there is a need to understand what patients say they want from access to general practice.

Aim: To examine what patients want from access to contemporary general practice in the UK.

Design and setting: This was a systematic review set in UK general practice.

Method: Studies were included that reported patient wants in relation to access to general practice in the UK since 2010. All empirical study designs were included, both quantitative and qualitative. The mixed-methods appraisal tool was used to assess study quality for contextual purposes. Narrative synthesis was applied to the included studies, with results presented using tables and text.

Results: In total, 33 studies were included. The review showed that patients wanted information about how to access the general practice, choice of clinician, choice of healthcare professional type, and choice of consultation mode. Patients wanted a nearby practice, with clean waiting rooms, easy appointment booking using simple systems and with short waiting times, and to be kept informed about the process.

Conclusion: The factors that patients want should be taken into consideration when changing or developing approaches to access. Future evaluations of care, and research, should explicitly consider what patients want from access in general practice.