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Background: The new Scottish GP contract introduced in April 2018 aims to improve quality of care through expansion of the multidisciplinary team (MDT) to enable GPs to spend more time as expert medical generalists with patients with complex needs., Aim: To explore patients' views on the changes in general practice in Scotland since the inception of the new contract., Design and Setting: Qualitative study with 30 patients (10 living in urban deprived areas, 10 living in urban affluent/mixed urban areas, and 10 living in remote and rural areas)., Method: In-depth semi-structured interviews with thematic analysis., Results: Patients were generally unaware of the new GP contract, attributing recent changes in general practice to the COVID-19 pandemic. Ongoing concerns included access to GP consultations (especially face-to-face ones), short consultation length with GPs, and damage to continuity of care and the GP-patient relationship. Most patients spoke positively about consultations with MDT staff but still wanted to see a known GP for health concerns that they considered potentially serious. These issues were especially concerning for patients with multiple complex problems, particularly those from deprived areas., Conclusion: Following the introduction of the new Scottish GP contract, patients in this study's sample were accepting of first contact care from the MDT but still wanted continuity of care and longer face-to-face consultations with GPs. These findings suggest that the expert generalist role of the GP is not being adequately supported by the new contract, especially in deprived areas, though further quantitative research is required to confirm this., (© The Authors.)

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., (© The Authors.)

Background: The Scottish Government's vision to transform primary care includes expansion of the primary care multidisciplinary team (MDT), formalised in the new GP contract in April 2018., Aim: To explore practitioners' views on the expansion of MDT working in Scotland., Design and Setting: Qualitative study with GPs and a range of MDT staff working in three different population settings in Scotland., Method: In-depth semi-structured interviews were carried out by telephone with 8 GPs and 19 MDT staff between May and June 2022. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted to identify commonalities and divergences in the interviews., Results: Internal challenges facing MDT staff included adapting to the fast pace of primary care, building new relationships, training and professional development needs, line management issues, and monitoring and evaluation of performance. External challenges included the ongoing effects of the COVID-19 pandemic, lack of time, difficulties with hybrid working, and low staff morale. Most GPs reported that expansion of their roles as expert medical specialists had not yet happened because their workload had not decreased (and in many cases had increased). In deprived areas, insufficient resources to deal with the high numbers of patients with complex multimorbidity remained a key issue. Interviewees in remote and rural settings felt the new contract did not take into account the unique challenges of providing primary care services in such areas, and recruitment and accommodation were cited as particular problems., Conclusion: Although there has been substantial expansion of the primary care MDT, which most GPs welcome, many challenges to effective implementation remain that must be addressed if transformation of primary care in Scotland is to become a reality., (© The Authors.)

Background: Multimorbidity poses major challenges to healthcare systems worldwide. Definitions with cut-offs in excess of ≥2 long-term conditions (LTCs) might better capture populations with complexity but are not standardised., Aim: To examine variation in prevalence using different definitions of multimorbidity., Design and Setting: Cross-sectional study of 1 168 620 people in England., Method: Comparison of multimorbidity (MM) prevalence using four definitions: MM2+ (≥2 LTCs), MM3+ (≥3 LTCs), MM3+ from 3+ (≥3 LTCs from ≥3 International Classification of Diseases, 10th revision chapters), and mental-physical MM (≥2 LTCs where ≥1 mental health LTC and ≥1 physical health LTC are recorded). Logistic regression was used to examine patient characteristics associated with multimorbidity under all four definitions., Results: MM2+ was most common (40.4%) followed by MM3+ (27.5%), MM3+ from 3+ (22.6%), and mental-physical MM (18.9%). MM2+, MM3+, and MM3+ from 3+ were strongly associated with oldest age (adjusted odds ratio [aOR] 58.09, 95% confidence interval [CI] = 56.13 to 60.14; aOR 77.69, 95% CI = 75.33 to 80.12; and aOR 102.06, 95% CI = 98.61 to 105.65; respectively), but mental-physical MM was much less strongly associated (aOR 4.32, 95% CI = 4.21 to 4.43). People in the most deprived decile had equivalent rates of multimorbidity at a younger age than those in the least deprived decile. This was most marked in mental-physical MM at 40-45 years younger, followed by MM2+ at 15-20 years younger, and MM3+ and MM3+ from 3+ at 10-15 years younger. Females had higher prevalence of multimorbidity under all definitions, which was most marked for mental-physical MM., Conclusion: Estimated prevalence of multimorbidity depends on the definition used, and associations with age, sex, and socioeconomic position vary between definitions. Applicable multimorbidity research requires consistency of definitions across studies., (© The Authors.)

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., (© The Authors.)

Background: Social prescribing involving primary care-based 'link workers' is a key UK health policy that aims to reduce health inequalities. However, the process of implementation of the link worker approach has received little attention despite this being central to the desired impact and outcomes., Aim: To explore the implementation process of such an approach in practice., Design and Setting: Qualitative process evaluation of the 'Deep End' Links Worker Programme (LWP) over a 2-year period, in seven general practices in deprived areas of Glasgow., Method: The study used thematic analysis to identify the extent of LWP integration in each practice and the key factors associated with implementation. Analysis was informed by normalisation process theory (NPT)., Results: Only three of the seven practices fully integrated the LWP into routine practice within 2 years, based on the NPT constructs of coherence, cognitive participation, and collective action. Compared with 'partially integrated practices', 'fully integrated practices' had better shared understanding of the programme among staff, higher staff engagement with the LWP, and were implementing all aspects of the LWP at patient, practice, and community levels of intervention. Successful implementation was associated with GP buy-in, collaborative leadership, good team dynamics, link worker support, and the absence of competing innovations., Conclusion: Even in a well-resourced government-funded programme, the majority of practices involved had not fully integrated the LWP within the first 2 years. Implementing social prescribing and link workers within primary care at scale is unlikely to be a 'quick fix' for mitigating health inequalities in deprived areas., (© The Authors.)

Background: Scotland abolished the Quality and Outcomes Framework (QOF) in April 2016, before implementing a new Scottish GP contract in April 2018. Since 2016, groups of practices (GP clusters) have been incentivised to meet regularly to plan and organise quality improvement (QI) as part of this new direction in primary care policy., Aim: To understand the organisation and perceived impact of GP clusters, including how they use quantitative data for improvement., Design and Setting: Thematic analysis of semi-structured interviews with key stakeholders ( n = 17) and observations of GP cluster meetings ( n = 6) in two clusters., Method: This analytical strategy was combined with a purposive (variation) sampling approach to the sources of data, to try to identify commonalities across diverse stakeholder experiences of working in or on the idea of GP clusters. Variation was sought particularly in terms of stakeholders' level of involvement in improvement initiatives, and in their disciplinary affiliations., Results: There was uncertainty as to whether GP clusters should focus on activities generated internally or externally by the wider healthcare system (for example, from Scottish Health Boards), although the two observed clusters generally generated their own ideas and issues. Clusters operated with variable administrative/managerial and data support, and variable baseline leadership experience and QI skills. Qualitative approaches formed the focus of collaborative learning in cluster meetings, through sharing and discussion of member practices' own understandings and experiences. Less evidence was observed of data analytics being championed in these meetings, partly because of barriers to accessing the analytics data and existing data quality., Conclusion: Cluster development would benefit from more consistent training and support for cluster leads in small-group facilitation, leadership, and QI expertise, and data analytics access and capacity. While GP clusters are up and running, their impact is likely to be limited without further investment in developing capacity in these areas., (© The Authors.)

Background: Chronic kidney disease (CKD) is commonly comorbid with hypertension, diabetes, and cardiovascular disease (CVD). However, the extent of comorbidity in CKD across a range of concordant (shared pathophysiology and/or treatment) conditions and discordant (unrelated pathophysiology and/or different or contradictory treatment) conditions is not well documented., Aim: To ascertain the prevalence of comorbidity, across 39 physical and mental health comorbidities, in adults with CKD in a large, nationally representative primary care population., Design and Setting: Cross-sectional analysis of a primary care dataset representing 1 274 374 adults in Scotland., Method: This study was a secondary analysis of general practice electronic medical record data using binary logistic regression models adjusted for age, sex, and socioeconomic status. Data of adults aged ≥25 years and 40 long-term conditions were used., Results: A total of 98.2% of adults with CKD had at least one comorbidity, versus 51.8% in controls. After adjustment for age, sex, and deprivation, people with CKD were more likely to have 1 (adjusted odds ratio [aOR] 6.5, 95% confidence interval [CI] = 6.0 to 7.1), 2-3 (aOR 15.2, 95% CI = 14.0 to 16.5), 4-6 (odds ratio [OR] 26.6, 95% CI = 24.4 to 28.9), and ≥7 other conditions (OR 41.9, 95% CI = 38.3 to 45.8). Furthermore, all concordant (seven out of seven), the majority of discordant physical health conditions (17 out of 24), and mental health conditions (six out of eight) had statistically significant positive associations with CKD after adjustment., Conclusion: Chronic kidney disease is associated with extreme comorbidity across a wide range of mental and physical conditions. Routine care for people with CKD should include recognition and management of comorbidities, and clinical guidelines should support clinicians to do this., (© The Authors.)

Background: The COVID-19 pandemic has impacted the psychological health and health service utilisation of older adults with multimorbidity, who are particularly vulnerable., Aim: To describe changes in loneliness, mental health problems, and attendance to scheduled medical care before and after the onset of the COVID-19 pandemic., Design and Setting: Telephone survey on a pre-existing cohort of older adults with multimorbidity in primary care., Method: Mental health and health service utilisation outcomes were compared with the outcomes before the onset of the COVID-19 outbreak in Hong Kong using paired t -tests, Wilcoxon's signed-rank test, and McNemar's test. Loneliness was measured by the De Jong Gierveld Loneliness Scale. The secondary outcomes (anxiety, depression, and insomnia) were measured by the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder tool, and the Insomnia Severity Index. Appointments attendance data were extracted from a computerised medical record system. Sociodemographic factors associated with outcome changes were examined by linear regression and generalised estimating equations., Results: Data were collected from 583 older (≥60 years) adults. There were significant increases in loneliness, anxiety, and insomnia, after the onset of the COVID-19 outbreak. Missed medical appointments over a 3-month period increased from 16.5% 1 year ago to 22.0% after the onset of the outbreak. In adjusted analysis, being female, living alone, and having >4 chronic conditions were independently associated with increased loneliness. Females were more likely to have increased anxiety and insomnia., Conclusion: Psychosocial health of older patients with multimorbidity markedly deteriorated and missed medical appointments substantially increased after the COVID-19 outbreak., (©The Authors.)

Background: Social prescribing is a collaborative approach to improve inter-sectoral working between primary health care and community organisations. The Links Worker Programme (LWP) is a social prescribing initiative in areas of high deprivation in Glasgow, Scotland, that is designed to mitigate the negative impacts of the social determinants of health., Aim: To investigate issues relevant to implementing a social prescribing programme to improve inter-sectoral working to achieve public health goals., Design and Setting: Qualitative interview study with community organisation representatives and community links practitioners (CLPs) in LWP areas., Method: Audiorecordings of semi-structured interviews with 30 community organisation representatives and six CLPs were transcribed verbatim and analysed thematically., Results: Participants identified some benefits of collaborative working, particularly the CLPs' ability to act as a case manager for patients, and their position in GP practices, which operated as a bridge between organisations. However, benefits were seen to flow from new relationships between individuals in community organisations and CLPs, rather than more generally with the practice as a whole. Challenges to the LWP were related to capacity and funding for community organisations in the context of austerity. The capacity of CLPs was also an issue given that their role involved time-consuming, intensive case management., Conclusion: Although the LWP appears to be a fruitful approach to collaborative case management, integration initiatives such as social prescribing cannot be seen as 'magic bullets'. In the context of economic austerity, such approaches may not achieve their potential unless funding is available for community organisations to continue to provide services and make and maintain their links with primary care., (© British Journal of General Practice 2018.)

Background: Chronic obstructive pulmonary disease (COPD) is common, and a major cause of morbidity and mortality worldwide. Recent studies suggest that comorbidities of COPD increase the risk of hospitalisation, polypharmacy, and mortality, but their estimated prevalence varies widely in the literature., Aim: To evaluate the prevalence of 38 physical and mental health comorbidities in people with COPD, and compare findings with those for people without COPD in a large nationally representative dataset., Design and Setting: A cross-sectional data analysis on 1 272 685 adults in Scotland from 314 primary care practices., Method: Data on COPD, along with 31 physical and seven mental health comorbidities, were extracted. The prevalence of comorbidities was compared between people who did, and did not, have COPD, standardised by age, sex, and socioeconomic deprivation., Results: From the total sample, 51 928 patients had COPD (4.1%). Of these, 86.0% had at least one comorbidity, compared with 48.9% of people without COPD. Of those with COPD, 22.3% had ≥5 comorbid conditions compared with 4.9% of those who did not have COPD (adjusted odds ratio 2.63, 95% confidence interval = 2.56 to 2.70). In total, 29 of the 31 physical conditions and six of the seven mental health conditions were statistically significantly more prevalent in people who had COPD than those who did not., Conclusion: Patients with COPD have extensive associated comorbidities. There is a real need for guidelines and health care to reflect this complexity, including how to detect those common comorbidities that relate to both physical and mental health, and how best to manage them. Primary care, which is unique in terms of offering expert generalist care, is best placed to provide this integrated approach., (© British Journal of General Practice 2017.)

Background: Comorbidity is common in heart failure, but previous prevalence estimates have been based on a limited number of conditions using mainly non-primary care data sources., Aim: To compare prevalence rates of comorbidity and polypharmacy in those with and without chronic heart failure due to left ventricular systolic dysfunction (LVSD)., Design and Setting: A cross-sectional study of 1.4 million patients in primary care in Scotland., Method: Data on the presence of LVSD, 31 other physical, and seven mental health comorbidities, and prescriptions were extracted from a database of 1 424 378 adults. Comorbidity prevalence was compared in patients with and without LVSD, standardised by age, sex, and deprivation. Pharmacology data were also compared between the two groups., Results: There were 17 285 patients (1.2%) who had a diagnosis of LVSD. Compared with standardised controls, the LVSD group had greater comorbidity, with the biggest difference found for seven or more conditions (odds ratio [OR] 4.10; 95% confidence interval (CI] = 3.90 to 4.32). Twenty-five physical conditions and six mental health conditions were significantly more prevalent in those with LVSD relative to standardised controls. Polypharmacy was higher in the LVSD group compared with controls, with the biggest difference found for ≥11 repeat prescriptions (OR 4.81; 95% CI = 4.60 to 5.04). However, these differences in polypharmacy were attenuated after controlling for the number of morbidities, indicating that much of the additional prescribing was accounted for by multimorbidity rather than LVSD per se ., Conclusion: Extreme comorbidity and polypharmacy is significantly more common in patients with chronic heart failure due to LVSD. The efficient management of such complexity requires the integration of general and specialist expertise., (© British Journal of General Practice 2017.)

Background: Little is known about how smoking cessation practices in primary care differ for patients with coronary heart disease (CHD) who have different comorbidities., Aim: To determine the association between different patterns of comorbidity and smoking rates and smoking cessation interventions in primary care for patients with CHD., Design and Setting: Cross-sectional study of 81 456 adults with CHD in primary care in Scotland., Method: Details of eight concordant physical comorbidities, 23 discordant physical comorbidities, and eight mental health comorbidities were extracted from electronic health records between April 2006 and March 2007. Multilevel binary logistic regression models were constructed to determine the association between these patterns of comorbidity and smoking status, smoking cessation advice, and smoking cessation medication (nicotine replacement therapy) prescribed., Results: The most deprived quintile had nearly three times higher odds of being current smokers than the least deprived (odds ratio [OR] 2.76; 95% confidence interval [CI] = 2.49 to 3.05). People with CHD and two or more mental health comorbidities had more than twice the odds of being current smokers than those with no mental health conditions (OR 2.11; 95% CI = 1.99 to 2.24). Despite this, those with two or more mental health comorbidities (OR 0.77; 95% CI = 0.61 to 0.98) were less likely to receive smoking cessation advice, but absolute differences were small., Conclusion: Patterns of comorbidity are associated with variation in smoking status and the delivery of smoking cessation advice among people with CHD in primary care. Those from the most deprived areas and those with mental health problems are considerably more likely to be current smokers and require additional smoking cessation support., (© British Journal of General Practice 2017.)

Background: The UK Quality and Outcomes Framework (QOF) offers financial incentives to deliver high-quality care for individual diseases, but the single-disease focus takes no account of multimorbidity., Aim: To examine variation in QOF payments for two indicators incentivised in ≥1 disease domain., Design and Setting: Modelling study using cross-sectional data from 314 general practices in Scotland., Method: Maximum payments that practices could receive under existing financial incentives were calculated for blood pressure (BP) control and influenza immunisation according to the number of coexisting clinical conditions. Payments were recalculated assuming a single new indicator., Results: Payment varied by condition (£4.71-£11.08 for one BP control and £2.09-£5.78 for one influenza immunisation). Practices earned more for delivering the same action in patients with multimorbidity: in patients with 2, 3, and ≥4 conditions mean payments were £13.95, £21.92, and £29.72 for BP control, and £7.48, £11.21, and £15.14 for influenza immunisation, respectively. Practices in deprived areas had more multiple incentivised patients. When recalculated so that each incentivised action was only paid for once, all practices received less for BP control: affluent practices received more and deprived practices received less for influenza immunisation., Conclusion: For patients with single conditions, existing QOF payment methods have more than twofold variation in payment for delivering the same process. Multiple payments were common in patients with multimorbidity. A payment method is required that ensures fairness of rewards while maintaining adequate funding for practices based on actual workload., (© British Journal of General Practice 2016.)

Background: Universal access to health care, as provided in the NHS, does not ensure that patients' needs are met., Aim: To explore the relationships between multimorbidity, general practice funding, and workload by deprivation in a national healthcare system., Design and Setting: Cross-sectional study using routine data from 956 general practices in Scotland., Method: Estimated numbers of patients with multimorbidity, estimated numbers of consultations per 1000 patients, and payments to practices per patient are presented and analysed by deprivation decile at practice level., Results: Levels of multimorbidity rose with practice deprivation. Practices in the most deprived decile had 38% more patients with multimorbidity compared with the least deprived (222.8 per 1000 patients versus 161.1; P<0.001) and over 120% more patients with combined mental-physical multimorbidity (113.0 per 1000 patients versus 51.5; P<0.001). Practices in the most deprived decile had 20% more consultations per annum compared with the least deprived (4616 versus 3846, P<0.001). There was no association between total practice funding and deprivation (Spearman ρ -0.09; P = 0.03). Although consultation rates increased with deprivation, the social gradients in multimorbidity were much steeper. There was no association between consultation rates and levels of funding., Conclusion: No evidence was found that general practice funding matches clinical need, as estimated by different definitions of multimorbidity. Consultation rates provide only a partial estimate of the work involved in addressing clinical needs and are poorly related to the prevalence of multimorbidity. In these circumstances, general practice is unlikely to mitigate health inequalities and may increase them., (© British Journal of General Practice 2015.)

Background: Chronic pain and its associated distress and disability are common reasons for seeking medical help. Patients with chronic pain use primary healthcare services five times more than the rest of the population. Mindfulness has become an increasingly popular self-management technique., Aim: To assess the effectiveness of mindfulness-based interventions for patients with chronic pain., Design and Setting: Systematic review and meta-analysis including randomised controlled trials of mindfulness-based interventions for chronic pain. There was no restriction to study site or setting., Method: The databases MEDLINE(®), Embase, AMED, CINAHL, PsycINFO, and Index to Theses were searched. Titles, abstracts, and full texts were screened iteratively against inclusion criteria of: randomised controlled trials of mindfulness-based intervention; patients with non-malignant chronic pain; and economic, clinical, or humanistic outcome reported. Included studies were assessed with the Yates Quality Rating Scale. Meta-analysis was conducted., Results: Eleven studies were included. Chronic pain conditions included: fibromyalgia, rheumatoid arthritis, chronic musculoskeletal pain, failed back surgery syndrome, and mixed aetiology. Papers were of mixed methodological quality. Main outcomes reported were pain intensity, depression, physical functioning, quality of life, pain acceptance, and mindfulness. Economic outcomes were rarely reported. Meta-analysis effect sizes for clinical outcomes ranged from 0.12 (95% confidence interval [CI] = -0.05 to 0.30) (depression) to 1.32 (95% CI = -1.19 to 3.82) (sleep quality), and for humanistic outcomes 0.03 (95% CI = -0.66 to 0.72) (mindfulness) to 1.58 (95% CI = -0.57 to 3.74) (pain acceptance). Studies with active, compared with inactive, control groups showed smaller effects., Conclusion: There is limited evidence for effectiveness of mindfulness-based interventions for patients with chronic pain. Better-quality studies are required., (© British Journal of General Practice 2015.)

Background: The Quality and Outcomes Framework (QOF) has specific targets for body mass index (BMI) and blood pressure recording in major mental illness (MMI), diabetes, and chronic kidney disease (CKD). Although aspects of MMI (schizophrenia, bipolar disorder, and related psychoses) are incentivised, barriers to care may occur., Aim: To compare payment, population achievement, and exception rates for blood pressure and BMI recording in MMI relative to diabetes and CKD across the UK., Design and Setting: Analysis of 2012/2013 QOF data from 9731 UK general practices 2 years after the introduction of the mental health, BMI, and blood pressure QOF indicators., Method: Payment, exception, and population achievement rates for the MMI and CKD blood pressure indicators and the MMI and diabetes BMI indicators were calculated and compared., Results: UK payment and population achievement rates for BMI recording for MMI were significantly lower than for diabetes (payment: 92.7% versus 95.5% and population achievement: 84.0% versus 92.5%, P<0.001) and exception rates were higher (8.1% versus 2.0%, P<0.001). For blood pressure recording, UK payment and population achievement rates were significantly lower for MMI than for CKD (94.1% versus 97.8% and 87.0% versus 97.1%, P<0.001), while exception rate was higher (6.5% versus 0.0%, P<0.001). This was observed for all countries. Compared with England, Northern Ireland had higher population achievement rates for both mental health indicators, whereas Scotland and Wales had lower rates. There were no cross-jurisdiction differences for CKD and diabetes., Conclusion: Differences in payment, exception, and population achievement rates for blood pressure and BMI recording for MMI relative to CKD and diabetes were observed across the UK. These findings suggest potential inequalities in the monitoring of physical health in MMI within the UK primary care system., (© British Journal of General Practice 2014.)

Background: Multimorbidity occurs at a younger age in individuals in areas of high socioeconomic deprivation but little is known about the 'typology' of multimorbidity in different age groups and its association with socioeconomic status., Aim: To characterise multimorbidity type and most common conditions in a large nationally representative primary care dataset in terms of age and deprivation., Design and Setting: Cross-sectional analysis of 1 272 685 adults in Scotland., Method: Multimorbidity type of participants (physical-only, mental-only, mixed physical, and mental) and most common conditions were analysed according to age and deprivation., Results: Multimorbidity increased with age, ranging from 8.1% in those aged 25-34 to 76.1% for those aged ≥75 years. Physical-only (56% of all multimorbidity) was the most common type of multimorbidity in those aged ≥55 years, and did not vary substantially with deprivation. Mental-only was uncommon (4% of all multimorbidity), whereas mixed physical and mental (40% of all multimorbidity) was the most common type of multimorbidity in those aged <55 years and was two- to threefold more common in the most deprived compared with the least deprived in most age groups. Ten conditions (seven physical and three mental) accounted for the top five most common conditions in people with multimorbidity in all age groups. Depression and pain featured in the top five conditions across all age groups. Deprivation was associated with a higher prevalence of depression, drugs misuse, anxiety, dyspepsia, pain, coronary heart disease, and diabetes in multimorbid patients at different ages., Conclusion: Mixed physical and mental multimorbidity is common across the life-span and is exacerbated by deprivation from early adulthood onwards., (© British Journal of General Practice 2014.)

Background: Most patients with depression are managed in general practice. In deprived areas, depression is more common and poorer outcomes have been reported., Aim: To compare general practice consultations and early outcomes for patients with depression living in areas of high or low socioeconomic deprivation., Design and Setting: Secondary data analysis of a prospective observational study involving 25 GPs and 356 consultations in deprived areas, and 20 GPs and 303 consultations in more affluent areas, with follow-up at 1 month., Method: Validated measures were used to (a) objectively assess the patient centredness of consultations, and (b) record patient perceptions of GP empathy., Results: PHQ-9 scores >10 (suggestive of caseness for moderate to severe depression) were significantly more common in deprived than in affluent areas (30.1% versus 18.5%, P<0.001). Patients with depression in deprived areas had more multimorbidity (65.4% versus 48.2%, P<0.05). Perceived GP empathy and observer-rated patient-centred communication were significantly lower in consultations in deprived areas. Outcomes at 1 month were significantly worse (persistent caseness 71.4% deprived, 43.2% affluent, P = 0.01). After multilevel multiregression modelling, observer-rated patient centredness in the consultation was predictive of improvement in PHQ-9 score in both affluent and deprived areas., Conclusion: In deprived areas, patients with depression are more common and early outcomes are poorer compared with affluent areas. Patient-centred consulting appears to improve early outcome but may be difficult to achieve in deprived areas because of the inverse care law and the burden of multimorbidity.

Background: Primary care increasingly deals with patients with multimorbidity, but relevant evidence-based interventions are scarce. Knowledge about multimorbidity over time is required to inform the development of effective interventions., Aim: This review identifies prospective cohort studies of multimorbidity in primary care to determine: their nature, scope and key findings; the methodologies used; and gaps in knowledge., Design: Systematic review., Method: Studies were identified by searching electronic databases, reviewing citations, and writing to authors. Searches were limited to adult populations with no restrictions on publication date or language. In total, 996 articles were identified and screened., Results: Of the 996 articles, six detailing five completed prospective cohort studies were selected as appropriate. Three of the studies were undertaken in the US and two in The Netherlands; none was nationally representative. The main focus of the studies was: healthcare utilisation and/or costs (n = 3); patients' physical functioning (n = 1); and risk factors for developing multimorbidity (n = 1). The conditions that were included varied widely. The findings of these studies showed that multimorbidity increased healthcare costs (n = 2), inpatient admission (n = 1), death rates (n = 1), and service use (n = 3), and reduced physical functioning (n = 1). One study identified psychosocial risk factors for multimorbidity. No study used random sampling, sample sizes were relatively small (414-3745 patients at baseline), and study duration was relatively short (1-4 years). No study focused on prevalence, treatment use, patient safety, service models, cultural or socioeconomic factors, and patient experience, and no study collected qualitative data., Conclusion: Few longitudinal studies based in primary care have investigated multimorbidity. Further large, long-term prospective studies are required to inform healthcare commissioning, planning, and delivery.

Over the past 5 years, general practice in the UK has undergone major change. Starting with the introduction of the new GMS contract in 2004, it has continued apace with the establishment of Postgraduate Medical Education Training Board, a GP training curriculum, and nMRCGP. The NHS is developing very differently in the four countries of the UK. Regulation of the profession is under review, and a system of relicensing, recertification, and revalidation is being introduced. The Essence project, initiated by RCGP Scotland in conjunction with International Futures Forum 4 years ago is a constructive response to these changes. It has included learning journeys, a discussion day for GPs, and commissioned short pieces of 100 words from GPs and patients. From an analysis of these, some characteristics of the essence of general practice have been defined. These include key roles and core personal qualities for GPs. It is argued that general practice has important and unique advantages - trust, coordination, continuity, flexibility, universal coverage, and leadership - which mean that it should continue to be central to the development of primary care throughout the UK.

Background: The new GMS contract has led to practice nurses playing an important role in the delivery of the Quality and Outcomes Framework (QOF)., Aim: This study investigated how practice nurses perceive the changes in their work since the contract's inception., Design of Study: A qualitative approach, sampling practice nurses from practices in areas of high and low deprivation, with a range of QOF scores., Setting: Glasgow, UK., Method: Individual interviews were conducted, audiotaped, transcribed, and analysed using a thematic approach., Results: Three themes emerged: roles and incentives, workload, and patient care. Practice nurses were positive about the development of their professional role since the introduction of the new GMS contract but had mixed views about whether their status had changed. Views on incentives (largely related to financial rewards) also varied, but most felt under-rewarded, irrespective of practice QOF achievement. All reported a substantial increase in workload, related to incentivised QOF domains with greater 'box ticking' and data entry, and less time to spend with patients. Although the structure created by the new contract was generally welcomed, many were unconvinced that it improved patient care and felt other important areas of care were neglected. Concern was also expressed about a negative effect of the QOF on holistic care, including ethical concerns and detrimental effects on the patient-nurse relationship, which were regarded as a core value., Conclusions: The new GMS contract has given practice nurses increased responsibility. However, discontent about how financial gains are distributed and negative impacts on core values may lead to detrimental long-term effects on motivation and morale.

Background: Evidence of the beneficial effects of longer consultations in general practice is limited., Aim: To evaluate the effect of increasing consultation length on patient enablement in general practice in an area of extreme socioeconomic deprivation., Design of Study: Longitudinal study using a 'before and after' design., Setting: Keppoch Medical Centre in Glasgow, which serves the most deprived practice area in Scotland., Method: Participants were 300 adult patients at baseline, before the introduction of longer consultations, and 324 at follow-up, more than 1 year after the introduction of longer consultations. The intervention studied was more time in complex consultations. Patient satisfaction, perceptions of the GPs' empathy, GP stress, and patient enablement were collected by face-to-face interview. Additional qualitative data were obtained by individual interviews with the GPs, relating to their perceptions of the impact of the longer consultations., Results: Response rates of 70% were obtained. Overall, 53% of consultations were complex. GP stress was higher in complex consultations. Patient satisfaction and perception of the GPs' empathy were consistently high. Average consultation length in complex consultations was increased by 2.5 minutes by the intervention. GP stress in consultations was decreased after the introduction of longer consultations, and patient enablement was increased. GPs' views endorsed these findings, with more anticipatory and coordinated care being possible in the longer consultations., Conclusion: More resource to provide more time in complex consultations in an area of extreme deprivation is associated with an increase in patient enablement.

Background: The Consultation Quality Index (CQI) is a holistic quality marker for GPs based on patient enablement, continuity of the care and consultation length., Aim: To evaluate the CQI-2, a new version of the CQI incorporating a process measure of GP empathy (the Consultation and Relational Empathy Measure)., Design of Study: Cross-sectional questionnaire study., Setting: General practice in the west of Scotland., Method: Empathy, enablement, continuity, and consultation length were measured in 3044 consultations involving 26 GPs in 26 different practices in the west of Scotland. CQI-2 scores were calculated and correlated with additional data on GPs' and patients' attitudes. Comparisons were also made with the UK-wide data from which the original CQI had been calculated., Results: CQI-2 scores were independent of deprivation, access, demographics, and case-mix. GPs with lower CQI-2 scores valued empathy and longer consultations less than these GPs with higher CQI-2 scores. 'Below average CQI-2' GPs (those in the bottom 25%) also felt less valued by patients and colleagues. Patients' showed less confidence in and gained less satisfaction from these doctors. Data ranges from the study were comparable with the UK data ranges used to construct the original CQI., Conclusions: The CQI-2 is a new measure of holistic interpersonal care. In a small but representative sample of GPs it appears to differentiate between below and above average doctors. CQI-2 scores may reflect important aspects of morale, core values and patient-centred care. There may be potential for its use as part of professional development and as a component of the general medical services contract.

Background: Patient enablement in general practice is known to be limited by consultation length. However, the processes within the consultation that lead to enablement are not well understood., Aims: To investigate patient enablement in a setting where time is less of a constraint than in primary care, in order to determine the importance of other factors in enablement., Design of Study: Exploratory questionnaire-based study., Setting: Two hundred consecutive outpatients attending four doctors at the Glasgow Homoeopathic Hospital, an NHS-funded integrated complementary and orthodox medicine unit., Method: Information was collected on enablement and a range of other factors, including the patients expectations, their perception of the doctors empathy, and the doctors own confidence in the doctor-patient relationship., Results: Although there were many factors that correlated with enablement, multi-regression analysis showed patients expectation, doctor's empathy (as perceived by the patient), and doctor's own confidence in the therapeutic relationship to be the three key factors. Together they accounted for 41% of the variation in enablement, with empathy being the single most important factor (66% of the explained variation in enablement)., Conclusion: Patient enablement at the Glasgow Homoeopathic Hospital is mainly related to the patients perception of the doctor's empathy.

Empathy is a complex multi-dimensional concept that has moral cognitive emotive and behavioural components Clinical empathy involves an ability to: (a) understand the patient's situation, perspective, and feelings (and their attached meanings); (b) to communicate that understanding and check its accuracy; and (c) to act on that understanding with the patient in a helpful (therapeutic) way. Research on the effect of empathy on health outcomes in primary care is lacking, but studies in mental health and in nursing suggest it plays a key role. Empathy can be improved and successfully taught at medical school especially if it is embedded in the students actual experiences with patients. A variety of assessment and feedback techniques have also been used in general medicine psychiatry and nursing. Further work is required to determine if clinical empathy needs to be, and can be, improved in the primary care setting.