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Background: Social determinants of health (SDOH) are the non-medical factors that impact health. Although geographical measures of deprivation are used, individual measures of social risk could identify those most at risk and generate more personalised care and targeted referrals to community resources. We know SDOH are important to health care, but it is not yet known whether their collection via the electronic health record (EHR) is acceptable and useful from the patient perspective. Aim: To synthesise relevant literature to explore patient perspectives on integrating information about SDOH into primary care EHRs, and the opportunities and challenges of its implementation in a general practice setting. Design & setting: Systematic review of primary care-based qualitative and mixed-method studies using thematic framework analysis. Method: Key databases were searched for articles reporting patient perspectives of SDOH collection within the primary care EHR. Qualitative and mixed-methods studies written in English were included. A framework analysis was conducted to identify themes. Results: From 14 included studies, the following five main themes were identified: rationale for SDOH screening and the anticipated outcomes; impact of the provider-patient relationship on patient perceptions; data, which included privacy concerns; screening process and referral; and recommendations for future research. Conclusion: Integration of information on SDOH into the EHR appears acceptable to patients. This review has added to the discussion of whether and how to implement SDOH screening and referral programmes into UK primary care systems. [ABSTRACT FROM AUTHOR]

Remote consulting has become part of the medical student clinical experience in primary care, but little research exists regarding the impact on learning. To describe the experiences of General Practitioner (GP) educators and medical students in using student-led remote consultations as an educational tool. A qualitative, explorative study conducted at four UK medical schools. GP educators and medical students were purposively sampled and interviewed. Nine themes arose: practical application, autonomy, heuristics, safety, triage of undifferentiated patients, clinical reasoning, patient inclusion in student education, student–patient interaction, and student–doctor interaction. Remote consulting has become part of the clinical placement experience. This has been found to expose students to a wider variety of clinical presentations. Verbal communication, history-taking, triage, and clinical reasoning skills were practised through remote consulting, but examination skills development was lacking. Students found building rapport more challenging, although this was mitigated by having more time with patients. Greater clinical risk was perceived in remote consulting, which had potential to negatively impact students' psychological safety. Frequent debriefs could ameliorate this risk and positively impact student–doctor relationships. Student autonomy and independence increased due to greater participation and responsibility. Pre-selection of patients could be helpful but had potential to expose students to lower complexity patients. Practice points Remote consulting confers unique educational benefits. Remote consulting can help develop history-taking and communication skills, as well as clinical reasoning skills. The psychological safety of the student and the supervisory risk of the tutor can be impacted by remote consulting, but frequent debriefs between the student and tutor can help mitigate this risk. Learning how to conduct remote, and face-to-face consultations is important in medical education. [ABSTRACT FROM AUTHOR]

Background: Chronic pain services in the United Kingdom are required to provide services which meet the diverse needs of patients, but little is known about the access and use of these services by Minority Ethnic groups. This protocol describes a scoping review that aims to assess whether adults who access secondary and tertiary chronic pain services are representative of the UK population. Methods: A scoping review will be conducted, comprising comprehensive searches of the literature using EMBASE, MEDLINE and CINAHL databases, and grey literature for records that address the study aims. Studies that meet the eligibility criteria will report on: (i) access to chronic pain services in secondary and/or tertiary care in the United Kingdom, (ii) by adults and, (iii) state the ethnicity of the involved participants within the demographics. Both qualitative and quantitative methodologies will be included to draw broad conclusions of what the cumulative evidence says on this topic. Publication dates are limited to between 2004 and 2021 as demographic data from studies published during this period best represent the UK population recorded in the 2011 UK census. The screening and selection process will be conducted by four reviewers and data will be extracted by one reviewer. A descriptive synthesis of the extracted data will be performed. Discussion: This scoping review will be among the first to explore whether the current adult population of those with chronic pain who are accessing chronic pain services in secondary and/or tertiary care across the United Kingdom are representative of the UK Minority Ethnic population. [ABSTRACT FROM AUTHOR]

Background: UK general practice is being shaped by new ways of working. Traditional GP tasks are being delegated to other staff with the intention of reducing GPs' workload and hospital admissions, and improving patients' access to care. One such task is patient-requested home visits. However, it is unclear what impact delegated home visits may have, who might benefit, and under what circumstances.Aim: To explore how the process of delegating home visits works, for whom, and in what contexts.Design and Setting: A review of secondary data on home visit delegation processes in UK primary care settings.Method: A realist approach was taken to reviewing data, which aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes. A range of data has been used including news items, grey literature, and academic articles.Results: Data were synthesised from 70 documents. GPs may believe that delegating home visits is a risky option unless they have trust and experience with the wider multidisciplinary team. Internal systems such as technological infrastructure might help or hinder the delegation process. Healthcare professionals carrying out delegated home visits might benefit from being integrated into general practice but may feel that their clinical autonomy is limited by the delegation process. Patients report short-term satisfaction when visited by a healthcare professional other than a GP. The impact this has on long-term health outcomes and cost is less clear.Conclusion: The delegation of home visits may require a shift in patient expectation about who undertakes care. Professional expectations may also require a shift, having implications for the balance of staffing between primary and secondary care, and the training of healthcare professionals. [ABSTRACT FROM AUTHOR]

Case presentations have totemic significance in medical sociology, in which they are analysed as emblematic of medical professional culture. This article makes a case for conceptualising these exchanges in terms of Mauss' account of gift-giving, which theorises sociality in terms of obligations voluntarily incurred and reciprocated and the performative recognition of hierarchy. This contrasts with two alternatives in existing literature: the case presentation as an instance of pedagogically oriented supervision and legitimate peripheral participation; and as representative of professional discourse more generally. We make our case for re-framing the case presentation in relation to video and audio data generated within a study of an Accident and Emergency department in the UK. We conclude that Mauss' concept of community allows us to see discursive phenomena that have been overlooked, and to theorise the work of junior doctors in terms of collegiality in a hierarchically organised profession, by contrast to a defective version of the work of their superiors or the manifestation of singular professional discourse. [ABSTRACT FROM AUTHOR]

Context: Globally, primary health care is facing workforce shortages. Longer and higher‐quality placements in primary care increase the likelihood of medical students choosing this specialty. However, the recruitment and retention of community primary care teachers are challenging. Relevant research was predominantly carried out in the 1990s. We seek to understand contemporary facilitators and barriers to general practitioner (GP) engagement with undergraduate education. Communities of practice (CoP) theory offers a novel conceptualisation, which may be pertinent in other community‐based teaching settings. Methods: Semi‐structured interviews were undertaken with 24 GP teachers at four UK medical schools. We purposively sampled GPs new to teaching, established GP teachers and GPs who had recently stopped teaching. We undertook NVivo‐assisted deductive and inductive thematic analysis of transcripts. We used CoP theory to interpret data. Results: Communities of practice theory illustrated that teachers negotiate membership of three CoPs: (i) clinical practice; (ii) the medical school, and (iii) teaching. The delivery of clinical care and teaching may be integrated or exist in tension. This can depend upon the positioning of the teaching and teacher as central or peripheral to the clinical CoP. Remuneration, workload, space and the expansion of GP trainee numbers impact on this. Teachers did not identify strongly as members of the medical school or a teaching community. Perceptions of membership were affected by medical school communication and support. The findings demonstrate gaps in medical school recruitment. Conclusions: This research demonstrates the marginalisation of primary care‐based teaching and proposes a novel explanation rooted in CoP theory. Concepts including identity and membership may be pertinent to other community‐based teaching settings. We recommend that medical schools review and broaden recruitment methods. Teacher retention may be improved by optimising the interface between medical schools and teachers, fostering a teaching community, increasing professional rewards for teaching involvement and altering medical school expectations of learning in primary care. The authors demonstrate, through use of Communities of Practice theory, ways to improve retention and recruitment of community‐based clinical teachers. [ABSTRACT FROM AUTHOR]

Background: General practice is increasingly used as a learning environment in undergraduate medical education in the UK. Aim: The aim of this project was to identify, summarise and synthesise research about undergraduate medical education in general practice in the UK. Methods: We systematically identified studies of undergraduate medical education within a general practice setting in the UK from 1990 onwards. All papers were summarised in a descriptive report and categorised into two in-depth syntheses: a quantitative and a qualitative in-depth review. Results: 169 papers were identified, representing research from 26 UK medical schools. The in-depth review of quantitative papers (n = 7) showed that medical students learned clinical skills as well or better in general practice settings. Students receive more teaching, and clerk and examine more patients in the general practice setting than in hospital. Patient satisfaction and enablement are similar whether a student is present or not in a consultation, however, patients experience lower relational empathy. Two main thematic groups emerged from the qualitative in-depth review (n = 10): the interpersonal interactions within the teaching consultation and the socio-cultural spaces of learning which shape these interactions. The GP has a role as a broker of the interactions between patients and students. General practice is a socio-cultural and developmental learning space for students, who need to negotiate the competing cultures between hospital and general practice. Lastly, patients are transient members of the learning community, and their role requires careful facilitation. Conclusions: General practice is as good, if not better, than hospital delivery of teaching of clinical skills. Our meta-ethnography has produced rich understandings of the complex relationships shaping possibilities for student and patient active participation in learning. [ABSTRACT FROM PUBLISHER]

Background: This article considers the moral notion of care in the context of Quality of Care discourses. Whilst care has clear normative implications for the delivery of health care it is less clear how Quality of Care, something that is centrally involved in the governance of UK health care, relates to practice. Discussion: This paper presents a social and ethical analysis of Quality of Care in the light of the moral notion of care and Bourdieu's conception of symbolic violence. We argue that Quality of Care bureaucracies show significant potential for symbolic violence or the domination of practice and health care professionals. This generates problematic, and unintended, consequences that can displace the goals of practice. Summary: Quality of Care bureaucracies may have unintended consequences for the practice of health care. Consistent with feminist conceptions of care, Quality of Care 'audits' should be reconfigured so as to offer a more nuanced and responsive form of evaluation. [ABSTRACT FROM AUTHOR]

Background: UK-based research conducted within a healthcare setting generally requires approval from the National Research Ethics Service. Research ethics committees are required to assess a vast range of proposals, differing in both their topic and methodology. We argue the methodological benchmarks with which research ethics committees are generally familiar and which form the basis of assessments of quality do not fit with the aims and objectives of many forms of qualitative inquiry and their more iterative goals of describing social processes/mechanisms and making visible the complexities of social practices. We review current debates in the literature related to ethical review and social research, and illustrate the importance of re-visiting the notion of ethics in healthcare research. Discussion: We present an analysis of two contrasting paradigms of ethics. We argue that the first of these is characteristic of the ways that NHS ethics boards currently tend to operate, and the second is an alternative paradigm, that we have labelled the 'iterative' paradigm, which draws explicitly on methodological issues in qualitative research to produce an alternative vision of ethics. We suggest that there is an urgent need to re-think the ways that ethical issues are conceptualised in NHS ethical procedures. In particular, we argue that embedded in the current paradigm is a restricted notion of 'quality', which frames how ethics are developed and worked through. Specific, pre-defined outcome measures are generally seen as the traditional marker of quality, which means that research questions that focus on processes rather than on 'outcomes' may be regarded as problematic. We show that the alternative 'iterative' paradigm offers a useful starting point for moving beyond these limited views. Summary: We conclude that a 'one size fits all' standardisation of ethical procedures and approach to ethical review acts against the production of knowledge about healthcare and dramatically restricts what can be known about the social practices and conditions of healthcare. Our central argument is that assessment of ethical implications is important, but that the current paradigm does not facilitate an adequate understanding of the very issues it aims to invigilate. [ABSTRACT FROM AUTHOR]

Abstract Waiting times in Accident and Emergency (A&E) Departments are a key performance indicator for the UK National Health Service (NHS) and are linked to medical decision making. We use the concept of medical disposal to consider the ways in which patients' medical problems are remoulded and transformed into a solvable problem enabling what he refers to as 'medical disposal'. Drawing on a study of 16 video-recorded cases from a single A&E Department in the UK, collected in 2014 and 2015, conversation analysis is used to explore how options for disposal (referral and discharge) are constructed and received in interactions between junior doctors and consultants. We consider the potential impact of information imbalances between junior doctors and consultants, as well as orientation to organisation goals in the form of standardised procedures and guidelines and constraints on time. In this way we demonstrate the interactional delicacy of discussions between junior doctors and consultants concerning moving patients on from A&E. We show how when juniors discuss cases with consultants the resultant decision making may be viewed as co-constructed. We make a case for detailed and nuanced understanding of interactions in A&E departments in order to understand the complexity of decision-making in this highly politically visible setting. Highlights • Emergency medicine (A&E) in the UK is a politically complex setting. • Discussions between junior doctors and consultants in A&E are interactionally delicate. • Decision making between junior doctors and consultants is co-constructed. • Conflicting concerns between junior doctor's need to learn and maintenance of service. [ABSTRACT FROM AUTHOR]

Background: UK general practice has been described as being in crisis. A shortage and exodus of GPs is an urgent and challenging problem, attracting significant media attention, widespread public debate, and policy action., Aim: Our review aims to examine which aspects of the healthcare system affect GP workforce sustainability, how, why, and for whom., Method: A realist review is an interpretive, theory-driven approach to evidence synthesis, that brings together data from quantitative, qualitative, mixed methods research, and the wider grey literature (e.g., policy documentation). Using this data allows us to examine a diverse range of evidence with a clear focus on understanding factors which support (or hinder) GP workforce sustainability, how these are shaped by contexts, and the mechanisms that underpin them. We identify important individual and system-level contexts that may be amenable to change., Results: We present our emerging findings in the form of a programme theory which explores human connection with patients, colleagues, and across organisations, gaining intellectual enrichment and learning systems comprising socially-situated knowledge. Relational continuity is key across these, supporting GP workforce sustainability. Challenges include standardisation, alienation and professional loneliness, inflexible organisation, and restrictive technologies., Conclusion: Our research generates new knowledge about the interdependencies between contexts, mechanisms, and outcomes. The findings can inform strategies and interventions intended to support, facilitate, and assist the GP workforce in delivering equitable and effective patient care. We identify critical gaps in knowledge and prioritise the expectations for scope and nature of future GP work and retention strategies., (© British Journal of General Practice 2024.)

Background: Total triage (TT) has the potential to achieve more equitable access to primary care, to improve the overall quality of care, and enhance health outcomes. TT has gained increasing attention from the public, policymakers, and academics., Aim: To examine relevant scientific literature regarding the implementation of TT, the reported opportunities and challenges for patients and staff, and implications for practice., Method: Medline, Embase, CINAHL, and Scopus were searched for articles and grey literature between 2013 and February 2023. Included documents described the implementation of TT during in-hours general practice and provided perspectives from patients/staff. Patients and stakeholders were involved throughout each stage of the review process. Findings were synthesised using a framework approach., Results: In total, 23 documents were included at full-text screening. Analysis highlights a range of TT approaches, sometimes conflating remote and TT systems. TT was seen to both increase and reduce workload. Consistently, patient and staff views worsened with TT use. TT can increase barriers to care access with potential to exacerbate inverse care laws across the UK. Critical knowledge gaps included patient co-production in TT systems and the role of reception teams to adapt systems to meet patients' needs., Conclusion: TT can influence patient access, safety, and equity. The approach may also generate profoundly different working styles for general practice. This review adds to current debates surrounding patient access and TT, and consequences for staff/patients. The findings can be used to aid practices when navigating the new GP contract and the implementation of new TT approaches., (© British Journal of General Practice 2024.)

Introduction: There are not enough general practitioners (GPs) in the UK National Health Service. This problem is worse in areas of the country where poverty and underinvestment in health and social care mean patients experience poorer health compared with wealthier regions. Encouraging more doctors to choose and continue in a GP career is a government priority. This review will examine which aspects of the healthcare system affect GP workforce sustainability, how, why and for whom., Methods and Analysis: A realist review is a theory-driven interpretive approach to evidence synthesis, that brings together qualitative, quantitative, mixed-methods research and grey literature. We will use a realist approach to synthesise data from the available published literature to refine an evidence-based programme theory that will identify the important contextual factors and underlying mechanisms that underpin observed outcomes relating to GP workforce sustainability. Our review will follow Pawson's five iterative stages: (1) finding existing theories, (2) searching for evidence, (3) article selection, (4) data extraction and (5) synthesising evidence and drawing conclusions. We will work closely with key stakeholders and embed patient and public involvement throughout the review process to refine the focus of the review and enhance the impact and relevance of our research., Ethics and Dissemination: This review does not require formal ethical approval as it draws on secondary data from published articles and grey literature. Findings will be disseminated through multiple channels, including publication in peer-reviewed journals, at national and international conferences, and other digital scholarly communication tools such as video summaries, X and blog posts., Prospero Registration Number: CRD42023395583., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Aim: To determine undergraduate medical students' teaching preferences and expectations for Culinary Medicine (CM) learning with a view to informing development of a CM course at a UK medical school., Setting: A single, urban UK medical school., Participants: 180 undergraduate medical students., Study Design: A cross-sectional questionnaire study collecting quantitative and qualitative (free-text) data., Methods and Outcome Measures: An online questionnaire consisting of 16 questions of various styles (Likert-type, multiple choice and free-text). Quantitative analysis of multiple choice and Likert-type scale questions was conducted. Qualitative thematic analysis was used to analyse the free-text responses and identify themes., Results: Three core themes related to students' understanding of CM were identified: (1) 'CM Learning': students' perceived relevance of CM knowledge, perceived relevance of CM to healthcare and their expectations for teaching; (2) 'The Relationship between Food and Health': links between diet, social factors and health; and (3) 'Evidence-based Medicine': students' perceptions about scientific principles underlying CM. Quantitative analysis revealed that, although 83% of students felt that learning CM is important for their future clinical practice, 56% felt unable to take a dietary history. 73% of students were dissatisfied with the quality, and 78% were dissatisfied with the quantity, of existing medical school teaching understood to be relevant to CM. Topics that students would like to be taught on a CM course included weight management and portion control. Students felt that problem-based style learning would be the most appropriate method for delivering CM teaching., Conclusions: This study revealed that medical students felt their dietary counsulting skills could be improved with further clinically relevant teaching in the undergraduate medical curriculum. Students' preferences for CM learning have been taken into consideration in the development of a CM course for fifth-year undergraduate students at a UK medical school, which is delivered during their General Practice placement., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Interprofessional learning (IPL), involving various professions within healthcare, has been proven to improve the quality of patient care by encouraging collaboration between professionals. Careful consideration of appropriate educational tools and content is required in order to facilitate the effective IPL. This study aimed to explore medical and pharmacy students' preconceptions of the role of virtual patients (VPs) as a learning tool for IPL within their education. A secondary aim was to elicit feedback to inform the development of new VP cases. Two focus groups (one with medical students and the other with pharmacy students), consisting of six students in each, were recruited. Participant perceptions regarding VP-based IPL were explored. Data were analysed using a thematic approach. Participants thought that there were some potential learning benefits of using VPs as part of their curriculum. Pharmacy students held increased value in VPs due to their limited access to patients during their education. Medical students challenged the role of VPs in their clinical development and concerned that VPs lack the flexibility required by doctors to use their judgement and work with uncertainty. Limited understanding of team members' roles in patient care and self-reported ignorance of the overlap in curricula appear to be key barriers for students in valuing the knowledge base of each other's profession and possible benefits of using VPs in joint learning. This study generated a number of key implications which need to be considered when introducing VP-based IPL.