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BackgroundNatriuretic peptide (NP) testing is recommended for patients presenting to primary care with symptoms of chronic heart failure (HF) to prioritise referral for diagnosis.AimTo report NP test performance at European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guideline referral thresholds.Design and settingDiagnostic accuracy study using linked primary and secondary care data (2004 to 2018).MethodThe sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NP testing for HF diagnosis was assessed.ResultsIn total, 229 580 patients had an NP test and 21 102 (9.2%) were diagnosed with HF within 6 months. The ESC NT-proBNP threshold ≥125 pg/mL had a sensitivity of 94.6% (95% confidence interval [CI] = 94.2 to 95.0) and specificity of 50.0% (95% CI = 49.7 to 50.3), compared with sensitivity of 81.7% (95% CI = 81.0 to 82.3) and specificity of 80.3% (95% CI = 80.0 to 80.5) for the NICE NT-proBNP ≥400 pg/mL threshold. PPVs for an NT-proBNP test were 16.4% (95% CI = 16.1 to 16.6) and 30.0% (95% CI = 29.6 to 30.5) for ESC and NICE thresholds, respectively. For both guidelines, nearly all patients with an NT-proBNP level below the threshold did not have HF (NPV: ESC 98.9%, 95% CI = 98.8 to 99.0 and NICE 97.7%, 95% CI = 97.6 to 97.8).ConclusionAt the higher NICE chronic HF guideline NP thresholds, one in five cases are initially missed in primary care but the lower ESC thresholds require more diagnostic assessments. NP is a reliable ‘rule-out’ test at both cut-points. The optimal NP threshold will depend on the priorities and capacity of the healthcare system.

BackgroundSkin complaints are common in primary care, and poor outcomes in long-term conditions are often due to low adherence to treatment. Shared decision making and self-management support may help, yet there is little understanding of patient involvement or the support provided by GPs.AimTo describe the content of primary care consultations for skin problems, including shared decision making practice, delivery of self-management advice, and follow-up.Design and settingCross-sectional study of video-recorded UK adult GP consultations and linked data.MethodA coding tool was developed and applied to all consultations with skin problems. Shared decision making was assessed using the observer OPTION5 scale.ResultsA total of 45/318 consultations (14.2%) related to one or more skin problems, which were discussed alongside other problems in 71.1% (32/45) of consultations. Of the 100 different problems discussed in these consultations, 51 were dermatological. The mean amount of time spent on skin problems in the consultations was 4 minutes 16 seconds. Medication was recommended for 66.7% (34/51) of skin problems, with low shared decision making (mean OPTION5 score = 10.7). Self-management advice (verbal only) was given for 47.1% (24/51) of skin problems. Most skin problems (84.3%; 43/51) were not referred to secondary care; 32.6% (14/43) of the skin problems not referred were seen again in primary care within 12 weeks, of which 35.7% (5/14) follow-up appointments were not planned.ConclusionIn this study, skin problems were usually presented alongside other complaints and resulted in a medication recommendation. Shared decision making was uncommon and self-management advice not consistently given, with re-attendance for the same problem common. GPs’ training should reflect how frequently skin problems are seen and seek to improve patient involvement in decision making and support self-management.

BackgroundA 2018 review into continuity of care with doctors in primary and secondary care concluded that mortality rates are lower with higher continuity of care.AimThis association was studied further to elucidate its strength and how causative mechanisms may work, specifically in the field of primary medical care.Design and settingSystematic review of studies published in English or French from database and source inception to July 2019.MethodOriginal empirical quantitative studies of any design were included, from MEDLINE, Embase, PsycINFO, OpenGrey, and the library catalogue of the New York Academy of Medicine for unpublished studies. Selected studies included patients who were seen wholly or mostly in primary care settings, and quantifiable measures of continuity and mortality.ResultsThirteen quantitative studies were identified that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality; a statistically significant protective effect of greater care continuity was found in nine, absent in two, and in one effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality. Improved clinical responsibility, physician knowledge, and patient trust were suggested as causative mechanisms, although these were not investigated.ConclusionThis review adds reduced mortality to the demonstrated benefits of there being better continuity in primary care for patients. Some patients may benefit more than others. Further studies should seek to elucidate mechanisms and those patients who are likely to benefit most. Despite mounting evidence of its broad benefit to patients, relationship continuity in primary care is in decline — decisive action is required from policymakers and practitioners to counter this.

BackgroundThe National Early Warning Score (NEWS) was introduced to standardise early warning scores (EWS) in England. It has been recommended that NEWS should be used in pre-hospital care but there is no published evidence that this improves outcomes. In 2015, the West of England Academic Health Science Network region standardised to NEWS across all healthcare settings. Calculation of NEWS was recommended for acutely unwell patients at referral into secondary care.AimTo evaluate whether implementation of NEWS across a healthcare system affects outcomes, specifically addressing the effect on mortality in patients with suspicion of sepsis (SOS).Design and settingA quality improvement project undertaken across the West of England from March 2015 to March 2019, with the aim of standardising to NEWS in secondary care and introducing NEWS into community and primary care.MethodData from the national dashboard for SOS for the West of England were examined over time and compared to the rest of England. Quality improvement methodology and statistical process control charts were used to measure improvement.ResultsThere was a reduction in mortality in the SOS cohort in the West of England, which was not seen in the rest of England over the time period of the project. Admissions did not increase. By March 2019, the West of England had the lowest mortality in the SOS cohort in England.ConclusionTo the authors’ knowledge, this is the first study demonstrating that use of NEWS in pre-hospital care is associated with improved outcomes in patients with SOS.

Frustrated. Exhausted. Burnt out. These are just some of the things our colleagues in primary care are feeling. I’m a GP registrar in the final 6 months of my training. It’s taken me 15 years to get to this stage after starting my medical education in 2006. It’s taken commitment, numerous exams, and countless sacrifices; but it has always been worth it knowing I was making a difference to my patients’ lives and the satisfaction their hard-earned respect and gratitude gleaned. But all that has changed. The recent vitriol aimed at primary care from mainstream and social media is demoralising, soul destroying, and incredibly damaging. Contrary to popular belief, we are and always have been open. Prior to entering GP training, I worked in secondary care as a medical and emergency medicine registrar. Like most of my hospital colleagues, I had little understanding of what actually happened in the mystical land of general practice. I do now. Having been the most senior doctor covering medical wards and emergency departments out of hours in busy inner-city hospitals, I can firmly say I have never been busier. The pressures are different, but the impact is real and …

BackgroundHidradenitis suppurativa (HS) is a chronic inflammatory skin disease that causes painful discharging nodules and skin tunnels. HS has associations with several systemic diseases, including cardiovascular disease (CVD), anxiety, and depression. High levels of chronic morbidity suggest an important role for primary care. However, little evidence exists regarding current management of HS and its comorbidities in UK general practice.AimTo describe current practice among UK GPs in treating and referring people with HS.Design & settingA web-based survey was circulated to UK Primary Care Dermatology Society (PCDS) members and GPs in Forth Valley, Scotland.MethodSurvey responses were analysed with descriptive statistics.ResultsA total of 134 UK GPs completed the survey. Seventy per cent (n = 94) saw at least one patient with HS in the previous month. Ninety-four per cent (n = 125/133) reported confidence in diagnosis, and 89% (n = 120/134) in initial treatment of HS. Most GPs initiated topical treatments and extended courses of oral antibiotic for HS, and many gave advice on adverse lifestyle factors. A minority provided analgesia, or screening for CVD risk factors, and depression. Most GPs referred to dermatology if secondary care input was required, with few referrals to specialised multidisciplinary services.ConclusionGPs regularly diagnose and manage uncomplicated HS, but screening for important comorbidities associated with HS is not common practice.

BackgroundThe Nuffield Trust’s report on NHS winter pressures highlights a lack of data for primary care, with a consequential focus on secondary care. An increase in data is required on the scale of the winter demand on primary care, so the need for investment in this area can be clearly seen.AimTo quantify seasonal variation in workload in primary and secondary care.Design & settingAnalysis of data for nine GP practices in Greater Manchester with a patient population of 75 421.MethodDescriptive and comparative analyses were performed for winter and summer periods in 2018–2019. Data were obtained from the North of England Clinical Support Unit (NECSU) via the Rapid Actionable Insight Driving Reform (RAIDR) toolkit, and EMIS Enterprise clinical audit tools.ResultsAccident and emergency (A&E) attendances increased by 4% (P = 0.035) during winter with no difference in the number of hospital admissions (P = 0.668). The number of problems (defined as separate diagnoses or causes for a GP consultation, for example, chest infection or medication request) seen in general practice increased by 61% (PPPP = 0.002).ConclusionGeneral practice observed a greater seasonal increase in presenting patients compared with secondary care. Any winter pressures strategy should target both respiratory illness and patients who self-refer to A&E. Transferring 50% of self-referrals in Manchester to GP appointments would achieve a £2.3 million cost saving. Increasing provision in primary care requires funding and increased appointments, but more importantly improved patient opportunities to easily access timely advice and assistance.

BackgroundPrevious work has demonstrated that the recording of acute health outcomes, such as myocardial infarction (MI), may be suboptimal in primary healthcare databases.AimTo assess the completeness and accuracy of the recording of stroke in UK primary care.Design & settingA population-based longitudinal cohort study.MethodCases of stroke were identified separately in Clinical Practice Research Datalink (CPRD) primary care records and linked Hospital Episode Statistics (HES). The recording of events in the same patient across the two datasets was compared. The reliability of strategies to identify fatal strokes in primary care and hospital records was also assessed.ResultsOf the 75 674 stroke events that were identified in either CPRD or HES data during the period of the study, 54 929 (72.6%) were recorded in CPRD and 51 013 (67.4%) were recorded in HES. Two-fifths (n = 30 268) of all recorded strokes were found in both datasets (allowing for a time window of 120 days). Among these 'matched' strokes the subtype was recorded accurately in approximately 75% of CPRD records (compared with coding in HES); however, 43.5% of ischaemic strokes in HES were coded as 'non-specific' strokes in CPRD data. Furthermore, 48.2% had same-day recordings, and 56.2% were date-matched within ±1 day.ConclusionThe completeness and accuracy of stroke recording is improved by the use of linked hospital and primary care records. For studies that have a time-sensitive research question, the use of linked, as opposed to stand-alone, CPRD data is strongly recommended.

BackgroundThe Newborn and Infant Physical Examination (NIPE) programme requires all babies to have a comprehensive health check at 6–8 weeks of age. These are typically completed by GPs. Although person-centred care has achieved prominence in maternity care policy in recent years, there is limited empirical evidence on what parents and/or carers expect from the check, and how far experiences meet their needs.Aim To explore the expectations and experiences of parents attending their GP for a baby check.Design & settingA qualitative study was undertaken in primary care in London.MethodContent analysis was undertaken of transcripts of semi-structured interviews. Interviews were conducted with a total of 16 participants (14 mothers and two fathers) who had recently attended for a 6-week check for their baby.ResultsDespite the availability of plentiful sources of general advice on infants’ health and development, a thorough check by a trusted GP was an important milestone for most parents. They had few specific expectations of the check in terms of what examinations were undertaken, but even experienced parents anticipated reassurance about their baby’s normal development. Many also hoped for reassurance about their own parenting. Parents appreciated GPs who explained what they were doing during the examination; space to raise any concerns; and combined mother and baby checks. Referrals to secondary care were generally experienced as reassuring rather than a source of anxiety.ConclusionThe baby check meets needs beyond those of the NIPE screening programme. Protecting the time for a thorough consultation is important for parents at what can be a vulnerable time.

Actinic keratoses (AK) are keratotic lesions presenting on chronically ultraviolet-exposed skin. The rate of malignant progression of a single AK to squamous cell carcinoma (SCC) remains uncertain, with reports ranging from 0.025%–20%.1,2 Patients receiving long-term immunosuppressive medications are at higher risk of developing AK.3 The estimated prevalence of AK is 19%–24% of individuals aged >60 years in the UK.3 Research suggests between 25%–70% of AK may spontaneously regress in a 1–4 year period.3 A Dutch qualitative study highlighted that some primary care clinicians’ principal approach to managing AK was treatment with cryosurgery, or referral to secondary care with patient-driven follow-up care.4 This article aims to inform GPs on the management of AK based on the British Association of Dermatologists (BAD) guidelines, the authors’ opinions on effective virtual consultations on AK, and when to refer patients to secondary care.

How do we move from supporting sick individuals to creating healthy communities? Allen et al 1 recently laid out their vision of: ‘… a near future where practices collaborate to share data and work alongside public health teams, patients, and local organisations to proactively engage with communities to make them more health-promoting places to grow, learn, work, and age. GPs would help identify modifiable determinants and support the development of interventions to address them.’ We propose a new workforce role that could help to make this vision a reality. Population health is the improvement of health and wellbeing, and the reduction of health inequalities, across an entire population. The King’s Fund outlined four pillars for population health: wider determinants of health; health behaviours and lifestyles; places and communities we live in; and an integrated health and care system.2 The shift towards population health is part of a wider global trend. The World Health Organization’s Declaration of Astana 3 and the unanimously adopted United Nations General Assembly resolution on universal health coverage4 name the integration of public health and primary care as the main vehicle for delivering better health outcomes. Co-producing population-level interventions to promote health and prevent disease is becoming a central activity of primary care all over the world. This fits with the social model of health that sees …

Do you ever feel like you lack a personal connection with your secondary care colleagues? Do you miss the ‘doctors’ lounge’ when you met and chatted over coffee? Would you take time for a speed dating event to get to know your fellow healthcare professionals? Would you value the opportunity to meet your secondary care colleagues in person? There is clear evidence — anecdotal and peer-reviewed — on the barriers to an effective ‘bridge’ or ‘interface’ between primary and secondary healthcare professionals. Within the cancer continuum, barriers include poor and delayed communication between primary care practitioners (PCPs) and cancer specialists, discrepancies regarding roles and expectations, and specialists’ uncertainty regarding the knowledge or training of the PCP.1,2 The impact of the gap between PCPs and specialists is not well defined but intuitively could lead to …

‘We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the fountain of life. Many of the things we need can wait. The child cannot. Right now is the time his bones are being formed, his blood is being made, and his senses are being developed. To him we cannot answer, “Tomorrow”, his name is today.’ Gabriela Mistral, Nobel Laureate.1 This poem delivers a powerful message; children are the future. Much of the current paediatric focus in The NHS Long Term Plan 2 relates to public health initiatives such as tackling obesity and ensuring emotional wellbeing; benefits that will take years or decades to realise. While these should not be forgotten, acute services for children and young people (CYP) are rarely prioritised when new models of care are considered, especially when the older population accounts for over 75% of NHS spending.2,3 What reason is there for commissioners and clinical leaders to focus on improving non-elective services for CYP when the needs of the frail and older population are so pressing? CYP under 18 years of age currently account for approximately 25% of attendances to primary and secondary care but

BackgroundPsychological problems are common among adolescents. Many GPs consider these problems challenging, even after diagnosis.AimTo explore how Norwegian GPs follow-up patients after a first diagnosis of a psychological problem at age 15–16 years.Design and settingNationwide longitudinal, register-based study using claims data for all GPs in the national list patient system, and for adolescents born in 1993 and 1994 (n = 129 499).MethodNational databases and registers were used to determine how many adolescents received a first diagnosis of a psychological problem in a GP consultation at age 15 or 16 years. Further consultations, collaborative contacts in primary care, and referrals to secondary care during the year after diagnosis were then identified and used as outcomes in regression analyses to investigate associations with initial diagnosis, parental education, and GP characteristics.ResultsIn total, 6809 (5.3%) adolescents received a first diagnosis of a psychological problem in a GP consultation at age 15 or 16 years. Internalising problems constituted 50.5% of initial diagnoses among females and 28.8% among males. Behaviour and attention problems accounted for 21.3% for females and 45.0% for males. In total, 46.6% of females and 39.9% of males had ≥1 follow-up consultation, and 32.8% of females and 27.0% of males were referred to secondary care. GPs reported primary care collaboration for 22.1% of females and 19.1% of males. GPs with larger patient lists had higher referral rates, but collaborated less within primary care. Males with a male GP had more follow-up consultations than males with a female GP.ConclusionGP follow-up after diagnosing psychological problems among adolescents is limited, but predominantly comprised referrals and some multidisciplinary cooperation. GP follow-up consultations should be studied more thoroughly, and the role of GPs warrants further policy discussions.

BackgroundDespite increasing use of computed tomography (CT), chest X-ray remains the first-line investigation for suspected lung cancer in primary care in the UK. No systematic review evidence exists as to the sensitivity of chest X-ray for detecting lung cancer in people presenting with symptoms.AimTo estimate the sensitivity of chest X-ray for detecting lung cancer in symptomatic people.Design and settingA systematic review was conducted to determine the sensitivity of chest X-ray for the detection of lung cancer.MethodDatabases including MEDLINE, EMBASE, and the Cochrane Library were searched; a grey literature search was also performed.ResultsA total of 21 studies met the eligibility criteria. Almost all were of poor quality. Only one study had the diagnostic accuracy of chest X-ray as its primary objective. Most articles were case studies with a high risk of bias. Several were drawn from non-representative groups, for example, specific presentations, histological subtypes, or comorbidities. Only three studies had a low risk of bias. Two primary care studies reported sensitivities of 76.8% (95% confidence interval [CI] = 64.5 to 84.2%) and 79.3% (95% CI = 67.6 to 91.0%). One secondary care study reported a sensitivity of 79.7% (95% CI = 72.7 to 86.8%).ConclusionThough there is a paucity of evidence, the highest-quality studies suggest that the sensitivity of chest X-ray for symptomatic lung cancer is only 77% to 80%. GPs should consider if further investigation is necessary in high-risk patients who have had a negative chest X-ray.

BackgroundPrevious studies have identified issues with the doctor–patient relationship in irritable bowel syndrome (IBS) that negatively impact symptom management. Despite this, little research has explored interactions between GPs and patients with refractory IBS. National guidelines suggest cognitive behavioural therapy (CBT) as a treatment option for refractory symptoms.AimTo explore perceptions of interactions with GPs in individuals with refractory IBS after receiving CBT for IBS or treatment as usual (TAU).Design and settingThis qualitative study was embedded within a trial assessing CBT in refractory IBS. Fifty-two participants took part in semi-structured interviews post-treatment in UK primary and secondary care.MethodInductive and/or data-driven thematic analysis was conducted to identify themes in the interview data.ResultsTwo key themes were identified: perceived paucity of GPs’ IBS knowledge and lack of empathy from GPs, but with acknowledgement that this has improved in recent years. These perceptions were described through three main stages of care: reaching a ‘last-resort diagnosis’; searching for the right treatment through a trial-and-error process, which lacked patient involvement; and unsatisfactory long-term management. Only CBT participants reported a shared responsibility with their doctors concerning symptom management and an intention to reduce health-seeking behaviour.ConclusionIn this refractory IBS group, specific doctor–patient communication issues were identified. Increased explanation of the process of reaching a positive diagnosis, more involvement of patients in treatment options (including a realistic appraisal of potential benefit), and further validation of symptoms could help. This study supports a role for CBT-based IBS self-management programmes to help address these areas and a suggestion that earlier access to these programmes may be beneficial.

BackgroundPopulation factors, including social deprivation and morbidity, predict the use of emergency departments (EDs).AimTo link patient-level primary and secondary care data to determine whether the association between deprivation and ED attendance is explained by multimorbidity and other clinical factors in the GP record.Design and settingRetrospective cohort study based in East London.MethodPrimary care demographic, consultation, diagnostic, and clinical data were linked with ED attendance data. GP Patient Survey (GPPS) access questions were linked to practices.ResultsAdjusted multilevel analysis for adults showed a progressive rise in ED attendance with increasing numbers of long-term conditions (LTCs). Comparing two LTCs with no conditions, the odds ratio (OR) is 1.28 (95% confidence interval [CI] = 1.25 to 1.31); comparing four or more conditions with no conditions, the OR is 2.55 (95% CI = 2.44 to 2.66). Increasing annual GP consultations predicted ED attendance: comparing zero with more than two consultations, the OR is 2.44 (95% CI = 2.40 to 2.48). Smoking (OR 1.30, 95% CI = 1.28 to 1.32), being housebound (OR 2.01, 95% CI = 1.86 to 2.18), and age also predicted attendance. Patient-reported access scores from the GPPS were not a significant predictor. For children, younger age, male sex, white ethnicity, and higher GP consultation rates predicted attendance.ConclusionUsing patient-level data rather than practice-level data, the authors demonstrate that the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use.

BackgroundChildren who do not attend (DNA) their hospital outpatient appointments are a concern because this potentially compromises the child’s health and incurs financial cost. Little is known about children who DNA or the views of GPs to non-attendance.AimTo describe the characteristics of children who DNA hospital paediatric outpatient appointments, and explore how GPs view and respond to DNAs.Design and settingA mixed methods study of data from all new referrals to a children’s hospital in the South West of England between 1 September and 31 October 2012.MethodData were extracted from patients’ hospital and GP records, and Stata was used to analyse the data quantitatively. Analysis focused on describing the characteristics of children who DNA, and the process of care that followed. Practices that had either the highest or lowest number of DNAs were purposefully sampled for GPs who had referred children to secondary care at the study hospital within the previous year. Interviews were held between May 2014 and July 2015, and were analysed thematically.ResultsChildren who DNA are more likely to be from an area of greater deprivation (adjusted odds ratio [AOR] 1.02, 95% confidence interval [CI] = 1.00 to 1.02, P = 0.04), and with a child protection alert in their hospital notes (AOR 2.72, 95% CI = 1.26 to 5.88, P = 0.01). Non-attendance is communicated poorly to GPs, rarely coded in patients’ GP records, and few GP practices have a formal policy regarding paediatric DNAs.ConclusionNon-attendance at hospital outpatient appointments may indicate a child’s welfare is at risk. Communication between primary and secondary care needs to be improved, and guidelines developed to encourage GPs to monitor children who DNA.

Everyone is talking about the NEWS — National Early Warning Scores.1 GPs will have noticed that ambulance call handlers are now routinely asking health professionals for a patient’s NEWS,2 and some areas are encouraging routine use of this scoring system in the community.3 So why has this happened and what is the evidence to support its use in the community? Should GPs be adopting NEWS or NEWS2 (an updated version that puts a greater emphasis on new onset confusion and recognises alternative oxygen saturations for people with respiratory failure) as part of their usual practice? Early warning scores (EWS), most recently NEWS2, have been used in hospitals for several years. In secondary care settings, they are primarily used by members of the team recording routine physiological observations in order to identify patients who are deteriorating clinically. The universal use of a common scoring system allows clinical information to be communicated efficiently across departments, clinical settings, and between clinical colleagues. Its usefulness as a common language, combined with the drive to identify sepsis early, have contributed to the widespread adoption and acceptance of NEWS2 in secondary care. Given the widespread use and acceptance in hospitals, it is only natural to consider whether it would also be helpful to use NEWS2 in the community. If paramedics, GPs, district nurses, and nursing home staff were all using the same system, then the benefits of this ‘common language’ in communicating physiological risk should help to identify those patients at greatest risk of deterioration and allow the prioritisation of resources accordingly. In …

BackgroundEnabling death at home remains an important priority in end-of-life care policy. However, hospital continues to be a more prevalent place of death than home in the UK, with admissions at the end-of-life often negatively labelled. Admissions are frequently attributed to an unsuitable home environment, associated with inadequate family care provision and insufficient professional care delivery.AimTo understand problems in professional and lay care provision that discourage death at home and lead to hospital admissions at the end of life.Design and settingA qualitative study of admission to a large English hospital of patients close to the end of their life.MethodRetrospective in-depth semi-structured interviews with healthcare professionals (n = 30) and next-of-kin (n = 3) involved in an admission. Interviews addressed why older patients (>65 years) close to the end of life are admitted to hospital. Interviews were transcribed and analysed thematically.ResultsHome-based end-of-life care appeared precarious. Hospital admission was considered by healthcare staff when there was insufficient nursing provision, or where family support, which was often extensive but under supported, was challenged. In these circumstances, home was not recognised to be a suitable place of care or death, justifying seeking care provision elsewhere.ConclusionChallenges in home care provision led to hospital admissions. Home end-of-life care depended on substantial input from family and professional carers, both of which were under-resourced. Where either care was insufficient to meet the needs of patients, home was no longer deemed to be desirable by healthcare staff and hospital care was sought.

BackgroundStrong evidence on the long-term safety and efficacy of different types of anticoagulants would help clinicians to prevent thromboembolic events among patients with atrial fibrillation (AF) while minimising the risk of haemorrhages.AimTo estimate the risk of thromboembolic and haemorrhagic events for patients with AF on antiplatelets or anticoagulants.Design and settingThis was a cohort study using routinely collected UK primary and secondary care clinical data from patients with AF, aged ≥18 years, and with an indication to receive anticoagulation before April 2012.MethodThe risk of ischaemic stroke or transient ischaemic attack (TIA), coronary heart disease (CHD), peripheral artery disease (PAD), or gastrointestinal (GI) haemorrhage, between 1 April 2012 and 1 April 2017, was estimated using multivariate Cox regression models for patients on antiplatelets only, a combination of antiplatelets and vitamin K antagonists (VKAs), or novel oral anticoagulants (NOACs), and compared with those on VKAs only.ResultsCompared with VKAs, antiplatelets were associated with a higher risk of stroke or TIA, hazard ratio (HR) 1.51, 95% confidence interval (CI) = 1.09 to 2.09, and GI haemorrhage, HR 1.79, 95% CI = 1.01 to 3.18. The risk of thromboembolic and haemorrhagic events was similar for those on a combination of antiplatelets and VKAs, or those on VKAs only. The risk was also similar for those on NOACs or VKAs, except for CHD, where it was higher for patients on NOACs, HR 2.07, 95% CI = 1.35 to 3.19.ConclusionAnticoagulants are associated with lower risk of thromboembolic and haemorrhagic events among patients with AF than antiplatelets. More research is required on the risk associated with VKAs or NOACs.

BackgroundGeneralist physician care is associated with improved patient outcomes. Despite initiatives to promote generalism in educational settings, recruitment to generalist disciplines remains less than required to serve societal needs. Increasingly this impacts not just general practice but also generalist specialties such as internal medicine, surgery, and paediatrics. One potential factor for this deficit is a lack of explicit attention to generalism as a praxis, including clarifying key aspects of generalist expertise.AimTo examine empirical clinical literature on generalism, and characterise how generalism is described and delivered by physicians in primary and secondary care.Design & settingA systematic mixed studies review (SMSR) including quantitative, qualitative, mixed-methods studies, and systematic reviews of physician generalist practice.MethodMEDLINE, Psycinfo, SocINDEX, Embase, Ovid HealthSTAR, Scopus, and Web of Science will be searched for English language studies from 1999 to present, using a structured search. Given study heterogeneity, quality appraisal will not be performed. Two reviewers will perform study selection for each study. Data extraction will focus on how generalism is defined and characterised, including the clinical care provided by generalists and patient experiences of generalist care. Quantitative and qualitative data will be summarised in tabular and narrative form. Convergent synthesis design will then be used to synthesise quantitative and qualitative data.ConclusionFindings will characterise generalism and generalist practice from a grassroots clinical perspective. By identifying similarities and differences across generalist disciplines, this work will inform more focused educational initiatives on generalism at undergraduate and postgraduate level, including collaborations between generalist disciplines.

Background Accurate assessment of the need for admission is challenging in Out of Hours (OOH) primary care. Understanding more about patient contacts where the decision to continue care in the community may have been incorrect could assist clinicians in assessing clinical risk. Aim To define the population contacting OOH primary care who are at higher risk of re-presenting to this service and requiring urgent transfer to secondary care within three days of their initial contact. Design and Setting Retrospective service evaluation of four years of patient contacts with Oxfordshire OOH primary care. Method Multivariable logistic regression was used to evaluate demographic and service delivery factors associated with increased risk of delayed escalation to secondary care Results Almost 1% of 496 931 patients contacting OOH primary care required escalation to secondary care within 3 days. Of these, 68.5% were initially discharged with no follow-up or advice to contact their GP; 14.7% were initially referred to secondary care. The odds of requiring escalation were increased with age (OR 1.010, 95% CI = 1.009 to 1.011, P Conclusion Older, prior users of the service, presenting at less busy times, are at greater risk of requiring secondary care referral from the OOH service within three days of their initial contact. These higher risk patient groups might benefit from active follow up by the OOH service.

Background There is little published research into the influence of email communication between primary and secondary care clinicians on patient care. Aim To explore the use of email communication between clinicians across the primary– secondary care interface, and how this may relate to patient care. Design and setting A qualitative study involving primary and secondary care services in the NHS Highland Health Board area, Scotland. Ten GPs and 12 hospital consultants were purposively sampled to reflect diversity. Method Eligible clinicians were invited to take part in a semi-structured interview. Data were analysed using a thematic analysis approach. Results Key themes that emerged for clinicians included general perceptions of email; using email in practice (managing workload, impact on patient journeys, and ‘quick answers’); system issues (variability and governance); relational aspects; and email skills. Conclusion Email communication between primary and secondary care clinicians generally has a positive impact on patient access to specialist expertise. Governance issues around the use of clinical email need to be defined. There may currently be a two-tier health service for those patients (and their GPs) requiring ‘quick answers’.

Background: Suboptimal treatment of cardiovascular diseases (CVD) among patients with severe mental illness (SMI) may contribute to physical health disparities.\ud \ud Aim: To identify SMI characteristics associated with meeting CVD treatment and prevention guidelines.\ud \ud Design and setting: Population-based electronic health record database linkage between primary care and the sole provider of secondary mental health care services in south east London, UK.\ud \ud Method: Cardiovascular disease prevalence, risk factor recording, and Quality and Outcomes Framework (QOF) clinical target achievement were compared among 4056 primary care patients with SMI whose records were linked to secondary healthcare records and 270 669 patients without SMI who were not known to secondary care psychiatric services, using multivariate logistic regression modelling. Data available from secondary care records were then used to identify SMI characteristics associated with QOF clinical target achievement.\ud \ud Results: Patients with SMI and with coronary heart disease and heart failure experienced reduced prescribing of beta blockers and angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACEI/ARB). A diagnosis of schizophrenia, being identified with any indicator of risk or illness severity, and being prescribed with depot injectable antipsychotic medication was associated with the lowest likelihood of prescribing.\ud \ud Conclusion: Linking primary and secondary care data allows the identification of patients with SMI most at risk of undertreatment for physical health problems.

Background There is increasing desire among service commissioners to treat arrhythmia in primary care. Accurate interpretation of the electrocardiogram (ECG) is fundamental to this. ECG interpretation has previously been shown to vary widely but there is little recent data. Aim To examine the interpretation of ECGs in primary and secondary care. Design and setting A cross-sectional survey of participants’ interpretation of six ECGs and hypothetical management of patients based on those ECGs, at primary care educational events, and a cardiology department in Leeds. Method A total of 262 primary care clinicians and 20 cardiology clinicians were surveyed via questionnaire. Answers were compared with expert electrophysiologist opinion. Results In primary care, abnormal ECGs were interpreted as normal by 23% of responders. ST elevation and prolonged QT were incorrectly interpreted as normal by 1% and 22%, respectively. In cardiology, abnormal ECGs were interpreted as normal by 3%. Conclusion ECG provision and interpretation remains inconsistent in both primary and secondary care. Primary care practitioners are less experienced and less confident with ECG interpretation than cardiologists, and require support in this area.

Background: Inflammatory markers can be helpful as part of the diagnostic workup for specific diseases or for monitoring disease activity. A third use is as a screening/triage tool to differentiate between the presence or absence of disease. Most research into inflammatory markers looks at diagnosis of specific diseases and comes from secondary care. Qualitative studies to explore when and why clinicians use these tests in primary care are lacking.Aim: To identify clinicians approaches to inflammatory marker testing in primary care.Design and setting: Qualitative study with 26 GPs and nurse practitioners. Method: Interviews were conducted using a semi-structured topic guide. Clinicians reviewed recent cases of inflammatory marker testing in their pathology inbox. Interviews were audio-recorded and transcribed. Qualitative analysis was conducted by two independent researchers. Results: Clinicians are uncertain about the appropriate use of inflammatory markers and differ in their approach to testing patients with undifferentiated symptoms. Normal or significantly elevated inflammatory markers are seen as helpful but mildly raised inflammatory markers in the context of non-specific symptoms are difficult to interpret. Clinicians describe a tension between not wanting to ‘miss anything’ and, on the other hand, being wary of picking up borderline abnormalities which can lead to cascades of further tests. Diagnostic uncertainty is a common reason for inflammatory marker testing, aiming to reassure, however paradoxically inconclusive results can generate a cycle of uncertainty and anxiety.Conclusion: Further research is needed to define when inflammatory marker testing is useful in primary care and how to interpret results.

BackgroundLung cancer screening with low-dose computed tomography (LDCT) has been shown to decrease mortality. Low lung cancer survival rates in the UK, driven primarily by late-stage presentation, provide the impetus for implementing screening. Nascent guidance on screening in the UK recommends primary care case-finding. However, the potential impact and acceptability on primary care, and the opportunistic utilisation of other case-finding routes, such as pharmacies, smoking cessation services, and respiratory clinics, have not been fully explored.AimTo explore healthcare professionals’ views and perspectives about lung cancer screening and their preparedness and willingness to be involved in its implementation.Design & settingA qualitative study was carried out with semi-structured interviews conducted with GPs, pharmacists, staff from smoking cessation services within Southwark and Lambeth in London, and staff from respiratory clinics in Guys’ and St Thomas’ NHS Foundation Trust in London between April 2018 and December 2018.MethodSixteen participants were interviewed and the interview transcripts were analysed thematically.ResultsParticipants described lung cancer screening as an important diagnostic tool for capturing lung cancer at an earlier stage and in increasing survivorship. However, the majority expressed a lack of awareness and understanding, uncertainty and concerns about the validity of screening, and the potential impact on their patients and workload.ConclusionStudy participants had mixed opinions about lung cancer screening and expressed their concerns about its implementation. Addressing these concerns by providing resources and effective and detailed guidelines for their use may lead to greater engagement and willingness to be involved in lung cancer screening.