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Limited data exist on the effect of travelling time on post-diagnosis cancer care and mortality. We analysed the impact of travel time to cancer treatment centre on secondary care contact time and one-year mortality using a data-linkage study in Scotland with 17369 patients. Patients with longer travelling time and island-dwellers had increased incidence rate of secondary care cancer contact time. For outpatient oncology appointments, the incidence rate was decreased for island-dwellers. Longer travelling time was not associated with increased secondary care contact time for emergency cancer admissions or time to first emergency cancer admission. Living on an island increased mortality at one-year. Adjusting for cancer-specific secondary care contact time increased the hazard of death, and adjusting for oncology outpatient time decreased the hazard of death for island-dwellers. Those with longer travelling times experience the cancer treatment pathway differently with poorer outcomes. Cancer services may need to be better configured to suit differing needs of dispersed populations. • Patients with high travel burden encounter the cancer treatment pathway differently. • They spend more time in hospital in the first year following cancer diagnosis. • Island dwellers have fewer outpatient appointments; this negatively affects survival. • Better configuration of cancer services is needed for dispersed populations. [ABSTRACT FROM AUTHOR]

In a previous publication we described the implementation and early evaluation of general practice paediatric scholarships in Scotland. We suggested that it was too early to be able to determine whether this significant investment will produce a return for Scotland in terms of enhanced roles in providing, leading or developing children's services in primary care or at the primary care/secondary care interface. This paper presents the results of a survey of the impact of the scholarship for the first six cohorts of the scholarship (119 General Practitioners). The response rate was 76%. Of the 90 respondents, almost half (44) have developed roles or areas of special paediatric interest either within or out with the practice, or in three cases both within and out with the practice. A total of 37 (43%) of those that continue to work within general practice reported that they have developed areas of special interest of benefit to the practice. Qualitative analysis of free text questions suggested that scholars had benefited from their experience in terms of increased confidence in dealing with child health problems, developing links with secondary care colleagues, and personal gain with respect to role development. [ABSTRACT FROM AUTHOR]

Background:In many countries, the medical primary-secondary care interface is central to the delivery of quality patient care. There is prevailing interest in developing initiatives to improve interface working for the benefit of health care professionals and their patients.Aim:To describe the development of an educational intervention designed to improve working at the primary-secondary care interface in NHS Scotland (United Kingdom) within the context of the Medical Research Council framework for the development and evaluation of complex interventions.Methods: A primary-secondary care interface focused Practice-based Small Group Learning (PBSGL) module was developed building upon qualitative synthesis and original research. A ‘meeting of experts’ shaped the module, which was subsequently piloted with a group of interface clinicians. Reflections on the module were sought from clinicians across NHS Scotland to provide contextual information from other areas.Findings:The PBSGL approach can be usefully applied to the development of a primary-secondary care interface-focused medical educational intervention. [ABSTRACT FROM AUTHOR]

Background: Improving the quality of care of at the medical primary-secondary care interface is both a national and a wider concern. In a qualitative exploration of clinicians' relationship at the interface, we want to study how both GPs and hospital specialists regard and behave towards each other and how this may influence patient care. Method: A qualitative interview study was carried out in primary and secondary care centres in NHS Highland health board area, Scotland. Eligible clinicians (general practitioners and hospital specialists) were invited to take part in a semi-structured interview to explore the implications of interface relationships upon patient care. A standard thematic analysis was used, involving an iterative process based on grounded theory. Results: Key themes that emerged for clinicians included communication (the importance of accessing and listening to one another, and the transfer of soft intelligence), conduct (referring to perceived inappropriate transfer of workload at the interface, and resistance to this transfer), relationships (between interface clinicians and between clinicians and their patients), and unrealistic expectations (clinicians expressing idealistic hopes of what their colleagues at the other interface could achieve). Conclusion: The relationship between primary and secondary care clinicians, and, in particular, difficulties and misunderstandings can have an influence upon patient care. Addressing key areas identified in the study may help to improve interface relationships and benefit patient care. [ABSTRACT FROM AUTHOR]

Objective: There is evidence of substantial ethnic variations in asthma morbidity and the risk of hospitalisation, but the picture in relation to lower respiratory tract infections is unclear. We carried out an observational study to identify ethnic group differences for lower respiratory tract infections.Design: A retrospective, cohort study.Setting: Scotland.Participants: 4.65 million people on whom information was available from the 2001 census, followed from May 2001 to April 2010.Main Outcome Measures: Hospitalisations and deaths (any time following first hospitalisation) from lower respiratory tract infections, adjusted risk ratios and hazard ratios by ethnicity and sex were calculated. We multiplied ratios and confidence intervals by 100, so the reference Scottish White population's risk ratio and hazard ratio was 100.Results: Among men, adjusted risk ratios for lower respiratory tract infection hospitalisation were lower in Other White British (80, 95% confidence interval 73-86) and Chinese (69, 95% confidence interval 56-84) populations and higher in Pakistani groups (152, 95% confidence interval 136-169). In women, results were mostly similar to those in men (e.g. Chinese 68, 95% confidence interval 56-82), although higher adjusted risk ratios were found among women of the Other South Asians group (145, 95% confidence interval 120-175). Survival (adjusted hazard ratio) following lower respiratory tract infection for Pakistani men (54, 95% confidence interval 39-74) and women (31, 95% confidence interval 18-53) was better than the reference population.Conclusions: Substantial differences in the rates of lower respiratory tract infections amongst different ethnic groups in Scotland were found. Pakistani men and women had particularly high rates of lower respiratory tract infection hospitalisation. The reasons behind the high rates of lower respiratory tract infection in the Pakistani community are now required. [ABSTRACT FROM AUTHOR]

Objectives This paper outlines a model developed by NHS Education for Scotland to pilot consultant appraiser training. The training was aimed at both new/inexperienced appraisers and experienced appraisers. A Course for New/Inexperienced Appraisers was held over 2 days and the Experienced Course over 1 day. Both are described, as is an initial tutor induction day designed to recruit consultant tutors who could contribute to delivering the courses. A thorough qualitative evaluation of the courses was undertaken and this is reported. The paper also discusses the desirability and implications of rolling out the pilot on a wider scale. Method A qualitative evaluation design using interviews to collect feedback from participants who had attended all three courses - the Induction event, the Inexperienced Appraiser Course and the Experienced Appraiser Course - was employed. Telephone interviews were transcribed and analysed using framework analysis and aided by NVivo 7. Results The response of those interviewed for this evaluation of the three courses was very positive. The content, organization, skills of the tutors and usefulness of the courses were commended. Suggested improvements were relatively minor and included: introducing more material on the requirements of revalidation, more small group discussions and making the course more secondary care-orientated. However, it was recognized that with the requirements for 'enhanced' appraisal and revalidation still uncertain, this created difficulties and the course would evolve to take account of further developments. Conclusions The training piloted represents an effective way to train consultants in appraisal skills. Interviewees were supportive of the pilot being continued: either nationally or cascaded down locally. Exactly what model is achievable and desirable will depend on the number of appraisers to be trained and the availability of resources to support 'enhanced' appraisal in secondary care. [ABSTRACT FROM AUTHOR]

Objective To determine the current practices in relation to weight management currently provided for overweight/obese patients attending different secondary care outpatient clinics. Methods Postal questionnaire sent to 100 consultant clinicians working in a range of specialist areas in three NHS Trust areas in Scotland, between January and March 2004. Results Overall response rate was 55%. Only 9% (five) of clinicians reported having a protocol in place for the management of patients who were overweight or obese. Lack of expertise and inaccessibility to expertise were cited frequently as reasons for having no protocol in place. Fifty-one per cent felt that weight management (including obesity treatment) should be undertaken by a specialist service either run by general practitioners (GPs), or by clinicians in a secondary care setting. Around a third of all those surveyed reported willingness to incorporate obesity management within their own routine specialty practice. Conclusion Clinicians acknowledged the adverse health effects of obesity within their specialist area, but felt unskilled and under-resourced to provide effective management. Effective prevention and management are required to challenge the obesity epidemic and will require the involvement of both primary and secondary care NHS settings. It is encouraging that a third of respondents felt prepared to incorporate obesity and weight management within their routine specialist practice. [ABSTRACT FROM AUTHOR]

Background: Increasing the uptake of HIV testing in people who may have undiagnosed HIV is essential to reduce the morbidity associated with late HIV diagnosis., Methods: We conducted a multicentre, longitudinal, mixed-methods study, surveying the attitudes, knowledge and practice of non-HIV specialist hospital physicians in South-East Scotland and North-East England with respect to HIV testing., Results: We found that although awareness of indications for HIV testing had improved over time, only 13% of clinicians recognised all of the surveyed HIV indicator conditions. Physicians were better at recognising the indicator conditions relevant to their specialty. The perception of working with a low-risk patient population was the most frequently cited barrier to offering an HIV test. Only a third of study respondents had requested more than 10 HIV tests in the preceding year., Conclusions: Our study supports a need for targeted and sustained educational initiatives to increase rates of HIV testing in secondary care., Competing Interests: No conflict of interests declared

Objectives: Following the outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and the subsequent global spread of the 2019 novel coronavirus disease (COVID-19), health systems and the populations who use them have faced unprecedented challenges. We aimed to measure the impact of COVID-19 on the uptake of hospital-based care at a national level., Design: The study period (weeks ending 5 January to 28 June 2020) encompassed the pandemic announcement by the World Health Organization and the initiation of the UK lockdown. We undertook an interrupted time-series analysis to evaluate the impact of these events on hospital services at a national level and across demographics, clinical specialties and National Health Service Health Boards., Setting: Scotland, UK., Participants: Patients receiving hospital care from National Health Service Scotland., Main Outcome Measures: Accident and emergency (A&E) attendances, and emergency and planned hospital admissions measured using the relative change of weekly counts in 2020 to the averaged counts for equivalent weeks in 2018 and 2019., Results: Before the pandemic announcement, the uptake of hospital care was largely consistent with historical levels. This was followed by sharp drops in all outcomes until UK lockdown, where activity began to steadily increase. This time-period saw an average reduction of -40.7% (95% confidence interval [CI]: -47.7 to -33.7) in A&E attendances, -25.8% (95% CI: -31.1 to -20.4) in emergency hospital admissions and -60.9% (95% CI: -66.1 to -55.7) in planned hospital admissions, in comparison to the 2018-2019 averages. All subgroup trends were broadly consistent within outcomes, but with notable variations across age groups, specialties and geography., Conclusions: COVID-19 has had a profoundly disruptive impact on hospital-based care across National Health Service Scotland. This has likely led to an adverse effect on non-COVID-19-related illnesses, increasing the possibility of potentially avoidable morbidity and mortality. Further research is required to elucidate these impacts.

Aims We have conducted a survey of administrative data, aiming to investigate the reported provision of dental extraction under general anaesthesia in the NHS for adults in secondary care in the following aspects: 1) anaesthetic data accessibility by NHS organisations; 2) the number and proportion of dental extraction episodes by anaesthetic modality and procedure type; 3) the economic cost of dental general anaesthesia (DGA) for adults; 4) variations in the anaesthetic provision between commissioning regions and organisation types. Methods We collected data from individual secondary care NHS organisations that provide dental extraction services in England, Wales and Scotland. A data collection form was devised to capture the number of episodes of dental extraction under each relevant oral surgery procedure code per anaesthetic modality per institution from October 2015 to September 2016. Results The majority (64.0%, n = 96,659) of the episodes were categorised into an anaesthetic modality; 39.2% (n = 37,902) under general anaesthesia, 18.7% (n = 18,050) under sedation, and 42.1% (n = 40,707) under local anaesthesia. The majority of sedation provision (84.9%) derived from dental hospitals. A substantial proportion (37.0%) of the episodes could not be assigned an anaesthetic modality. Variations in dental general anaesthesia activity were observed with respect to the commissioning regions and organisation types. The annual cost of adult DGA from 81 out of 150 organisations that provided DGA data was estimated to be over £19 million, based on the NHS payment by results tariff 2015-2016. Conclusion Our data suggest that the number of adult DGA episodes and the associated cost are considerable, and highlights the scope for improving the quality of data for commissioners and providers to support discussions over patient pathways.

Aim: (a) To report national trends for tonsillectomy, tonsillitis, peritonsillar abscess and deep neck space infection in secondary care. (b) To report national trends in sore throat consultations in primary care. (c) To report national trends in antibiotic prescribing in both primary and secondary care between 2011 and 2015., Design: Retrospective nationwide cohort study. Data requested from Information Statistics Department (ISD) Scotland for tonsillectomy, tonsillitis admissions, peritonsillar abscess admissions and deep neck space infection (DNSI) admissions in Scotland, between 1993/94 and 2015/16. Data for antibiotic prescriptions in general practice and hospital admissions between 2011 and 2015., Setting: Scottish ENT departments and GP practices., Participants: Scottish patients who underwent tonsillectomy or were admitted to hospital with tonsillitis, peritonsillar abscess or deep neck space infection. Scottish patients that attended their GP with tonsillitis., Results: Tonsillectomy rates between 1993/94 and 2015/16 decreased by 48% (P < 0.001). Over the same time period, there has been a corresponding 136% increase in tonsillitis admission (P < 0.001) and a 167% increase in peritonsillar abscess admissions, (P < 0.001). Between 1996/97 and 2015/16, there was a 500% increase in deep neck space abscesses (P < 0.001)., Conclusion: There has been a significant decrease in tonsillectomy rates over the past two decades. Over the same time period, there has been a significant increase in admissions to secondary care with tonsillitis, peritonsillar abscess and deep neck space infection. These changes have happened in the context of two separate national policies being introduced-Scottish Intercollegiate Guideline Network (SIGN) guidelines for management of sore throat and the Scottish Reduction in Antibiotic Prescribing., (© 2018 John Wiley & Sons Ltd.)

Background: Those living in rural areas have poorer cancer outcomes, but current evidence on how rurality impacts melanoma care and survival is contradictory., Aim: To investigate the impact of rurality on setting of melanoma excision and mortality in a whole-nation cohort., Design and Setting: Analysis of linked routine healthcare data comprising every individual in Scotland diagnosed with melanoma, January 2005-December 2013, in primary and secondary care., Method: Multivariate binary logistic regression was used to explore the relationship between rurality and setting of melanoma excision; Cox proportional hazards regression between rurality and mortality was used, with adjustments for key confounders., Results: In total 9519 patients were included (54.3% [ n = 5167] female, mean age 60.2 years [SD 17.5]). Of melanomas where setting of excision was known, 90.3% ( n = 8598) were in secondary care and 8.1% ( n = 771) in primary care. Odds of primary care excision increased with increasing rurality/remoteness. Compared with those in urban areas, those in the most remote rural locations had almost twice the odds of melanoma excision in primary care (adjusted odds ratio [aOR] 1.92; 95% confidence interval [CI] = 1.33 to 2.77). No significant association was found between urban or rural residency and all-cause mortality. Melanoma-specific mortality was significantly lower in individuals residing in accessible small towns than in large urban areas (adjusted hazards ratio [HR] 0.53; 95% CI = 0.33 to 0.87) with no trend towards poorer survival with increasing rurality., Conclusion: Patients in Scottish rural locations were more likely to have a melanoma excised in primary care. However, those in rural areas did not have significantly increased mortality from melanoma. Together these findings suggest that current UK melanoma management guidelines could be revised to be more realistic by recognising the role of primary care in the prompt diagnosis and treatment of those in rural locations., (© British Journal of General Practice 2018.)

Background: Electronic Healthcare Records (EHRs) are created to capture summaries of care and contact made to healthcare services. EHRs offer a means to analyse admissions to hospitals for epidemiological research. In the United Kingdom (UK), England, Scotland and Wales maintain separate data stores, which are administered and managed exclusively by devolved Government. This independence results in harmonisation challenges, not least lack of uniformity, making it difficult to evaluate care, diagnoses and treatment across the UK. To overcome this lack of uniformity, it is important to develop methods to integrate EHRs to provide a multi-nation dataset of health., Objective: To develop and describe a method which integrates the EHRs of Armed Forces personnel in England, Scotland and Wales based on variable commonality to produce a multi-nation dataset of secondary health care., Methods: An Armed Forces cohort was used to extract and integrate three EHR datasets, using commonality as the linkage point. This was achieved by evaluating and combining variables which shared the same characteristics. EHRs representing Accident and Emergency (A&E), Admitted Patient Care (APC) and Outpatient care were combined to create a patient-level history spanning three nations. Patient-level EHRs were examined to ascertain admission differences, common diagnoses and record completeness., Results: A total of 6,336 Armed Forces personnel were matched, of which 5,460 personnel had 7,510 A&E visits, 9,316 APC episodes and 45,005 Outpatient appointments. We observed full completeness for diagnoses in APC, whereas Outpatient admissions were sparsely coded; with 88% of diagnoses coded as "Unknown/unspecified cause of morbidity". In addition, A&E records were sporadically coded; we found five coding systems for identifying reason for admission., Conclusion: At present, EHRs are designed to monitor the cost of treatment, enable administrative oversight, and are not currently suited to epidemiological research. However, only small changes may be needed to take advantage of what should be a highly cost-effective means of delivering important research for the benefit of the NHS., (Copyright © 2018 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: In contrast with most published evidence, studies from north-east Scotland suggest that GPs may be as good at treating skin cancers in primary care as secondary care specialists., Aim: To compare the quality of skin cancer excisions of GPs and secondary care skin specialists in east and south-east Scotland., Design and Setting: A retrospective analysis of reports from GPs in Lothian, Fife, and Tayside regions., Method: Skin cancer histopathology reports from GPs in Lothian, Fife, and Tayside regions in 2010 were compared with reports from skin specialists in November 2010. The histopathology reports were rated for completeness and adequacy of excision., Results: A total of 944 histopathology reports were analysed. In 1 year, GPs biopsied or excised 380 skin cancers. In 1 month, dermatologists biopsied or excised 385 skin cancers, and plastic surgeons 179 skin cancers. 'High risk' basal cell carcinomas (BCC) comprised 63.0% of BCC excised by GPs. For all skin cancer types, GPs excised smaller lesions, and had a lower rate of complete excisions compared with skin specialists. A statistical difference was demonstrated for BCC excisions only., Conclusion: GPs in east and south-east Scotland excise a number of skin cancers including malignant melanoma (MM), squamous cell carcinoma (SCC) and high-risk BCC. Despite removing smaller lesions, less commonly on difficult surgical sites of the head and neck, GP excision rates are lower for all skin cancers, and statistically inferior for BCC, compared with secondary care, supporting the development of guidelines in Scotland similar to those in other UK regions. Poorer GP excision rates may have serious consequences for patients with high-risk lesions., (© British Journal of General Practice 2014.)

Background: Constipation is a common chronic childhood condition referred to secondary care. Effective treatment requires early intervention, prolonged medication to soften stools and behavioural support to achieve a regular habit of sitting on the toilet to pass a stool. The purpose of this audit and service development was to assess routine consultant paediatrician-led care against minimum standards and if appropriate to develop a nurse-led intervention. The new care package could then be tried out within general paediatric clinics in Glasgow as a service evaluation. NICE guideline (CG99) has a research recommendation to compare nurse-led care with routine consultant-led care., Methods: Design was an audit then development of a nurse-led intervention followed by a service evaluation. Participants were children (age 0-13 years), referred by their General Practitioner (GP) to the Royal Hospital for Sick Children Glasgow, with constipation the main problem in the GP letter. The audit covered appointment waiting times, intervention provided, initial follow-up and parental satisfaction with routine consultant-led practice. The nurse-led intervention focused on self-help psychology practice with NICE guideline medical support. This was compared with routine consultant paediatrician care in a service evaluation., Results: The audit found consultant-led care had long waiting times, delayed initial follow-up and variable intervention. The new nurse-led intervention is described in detail. The nurse-led intervention performed well compared with consultant-led care. Less 'nurse-led' children, 3/45 (7%), were still constipated passing less than 3 stools per week compared with 8/58 (14%) receiving consultant-led care. Less 'nurse-led' parents, 10/45 (22%), reported their child having pain passing stools in the previous week compared with consultant-led care, 26/58 (45%). The proportion of children, over 4 years, free from soiling accidents was similar, 15/23 (65%) in the nurse-led group and 18/29 (62%) with consultant-led care. Parental satisfaction was slightly better in the nurse-led group., Conclusion: It is difficult to achieve minimum standards using routine consultant-led care for children referred by their GP with constipation. Nurse-led early intervention is feasible and has produced promising results in a service evaluation. An exploratory trial is planned to develop a teaching module, robust outcomes including costs and benefits, and methodology for a definitive trial recommended by NICE.

Practice-based small group learning (PBSGL) is an established approach for continuing professional development (CPD) for GPs in Scotland. This paper describes an extension of the PBSGL approach to support the learning and development of educational supervisors from both hospital and general practice, working together in peer-facilitated small groups to address topic-specific, evidence-based educational modules. Four groups met on three occasions each and qualitative data were gathered from interviews with the facilitators and the participants. This was supplemented with observational data of the group process and function. Both GPs and consultants enjoyed the format and were very positive about the experience of working together in this way. Commitment to change educational practice and reported actual changes in practice were evident.