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Clinical decision support systems relating to prescribing are available on general practice information technology systems, with warnings relating to drug–drug interactions and allergies. These tools can help us anticipate and avoid known side effects of drugs, but only after we have selected the drug. Combining these with renal function, liver function, other biophysical markers and pharmacogenomics information, can improve medicines optimisation and reduce adverse effects. Managing all these variables at the same time as conforming to disease guidelines is a challenge. The challenge is even greater when managing multi-morbidity and the associated polypharmacy.

The COVID-19 Genomics UK (COG-UK) Consortium was created to deliver large-scale and rapid whole-genome virus sequencing. Its data will help Public Health Agencies to manage the COVID-19 pandemic in the UK and inform vaccine research efforts. From a wider perspective, data sharing around the genomics of viruses (and bacteria, protozoa parasites and fungi) offers researchers contrasting perspectives and new biological insights into the evolution of microbes and the development of new tools in managing infectious disease, which on a global scale causes significant mortality. Genomics has an evolving role in pathogen diagnosis and surveillance.

Identification of a genetic disorder within a family raises the question of risk of the genetic disorder to other family members and future pregnancies. This question is particularly pertinent when considering reproductive risks and choices. Primary care is crucial in identifying and managing couples at increased risk of having an affected pregnancy, both pre-conceptually and in early pregnancy, before the first midwife appointment. Genomic technologies have an increasing role in antenatal screening programmes and antenatal testing; specifically non-invasive prenatal testing considered in this article. Infertility, recurrent miscarriage and fetal abnormality may all have an underlying genetic cause.

Advances in genomics have vastly increased our understanding of inherited cancer risk and underlying cancer predisposition syndromes, thereby underpinning a revolution in the diagnosis and treatment of cancer itself. Concern regarding family history of cancer is a common presentation within primary care. This article provides an overview of the role of primary care practitioners in the clinical identification and management of inherited cancer risk within primary care including risk assessment, screening and surveillance. The article will consider management issues, including access to genomic testing and advice on risk-reduction measures. The role of genomics in cancer diagnosis and treatment and future applications will be outlined.

The continued evolution of the NHS Genomic Medicine Service, alongside improved accessibility to genomic testing through other routes, will increase consultations regarding genomics issues within primary care. GP trainees identify ‘genetics’ as a learning gap in their training, with anecdotal evidence suggesting that completion of this section in the curriculum is ‘challenging’. To support trainees and trainers in meeting this aspect of GP training, this article outlines relevant educational theory, initiatives and resources in genomics from a primary care perspective. This information will equip the learner with approaches and tools to promote confidence in learning and managing issues involving genomic medicine in practice.

Advances in genomic technology and the launch of the NHS Genomic Medicine Service (GMS) in 2018 have firmly embedded genomic testing within routine clinical care. As the gateway to the NHS, primary care practitioners will be managing increasing numbers of patients who are eligible for genomic testing, or who present with their own, or a family member’s genomic test result. This article provides an overview of recent developments in the field of genomics, explains key concepts and terminology, and details the current organisation of the genomics services under the GMS. It also discusses some common presentations within primary care to highlight the relevance of genomics to frontline GPs.

The exceptional advances in genomic medicine in the last two decades, since the sequencing of the human genome, have already had a major impact on healthcare in the UK. Until recently this was predominantly in secondary and tertiary care, but we must now integrate ‘mainstream’ genomics in primary care. So far integration has of necessity been empirical, but must progress towards implementation research. We describe recent work undertaken by the RCGP and the NIHR CRN outlining areas where research is needed to fully integrate genomics into routine primary care and secure the future of these exciting developments.

BackgroundQuality improvement (QI) is a priority for general practice, and GPs are expected to participate in and provide evidence of QI activity. There is growing interest in harnessing the potential of electronic health records (EHR) to improve patient care by supporting practices to find cases that could benefit from a medicines review.AimTo develop scalable and reproducible prescribing safety reports using patient-level EHR data.Design and settingUK general practices that contribute de-identified patient data to the Clinical Practice Research Datalink (CPRD).MethodA scoping phase used stakeholder consultations to identify primary care QI needs and potential indicators. QI reports containing real data were sent to 12 pilot practices that used Vision GP software and had expressed interest. The scale-up phase involved automating production and distribution of reports to all contributing practices that used both Vision and EMIS software systems. Benchmarking reports with patient-level case review lists for two prescribing safety indicators were sent to 457 practices in December 2017 following the initial scale-up (Figure 2).ResultsTwo indicators were selected from the Royal College of General Practitioners Patient Safety Toolkit following stakeholder consultations for the pilot phase involving 12 GP practices. Pilot phase interviews showed that reports were used to review individual patient care, implement wider QI actions in the practice, and for appraisal and revalidation.ConclusionElectronic health record data can be used to provide standardised, reproducible reports that can be delivered at scale with minimal resource requirements. These can be used in a national QI initiative that impacts directly on patient care.

Objectives: To assess the feasibility and uptake of a community‐based prostate cancer (PCa) screening programme selecting men according to their genetic risk of PCa. To assess the uptake of PCa screening investigations by men invited for screening. The uptake of the pilot study would guide the opening of the larger BARCODE1 study recruiting 5000 men. Subjects and Methods: Healthy males aged 55–69 years were invited to participate via their general practitioners (GPs). Saliva samples were collected via mailed collection kits. After DNA extraction, genotyping was conducted using a study specific assay. Genetic risk was based on genotyping 130 germline PCa risk single nucleotide polymorphisms (SNPs). A polygenic risk score (PRS) was calculated for each participant using the sum of weighted alleles for 130 SNPs. Study participants with a PRS lying above the 90th centile value were invited for PCa screening by prostate magnetic resonance imaging (MRI) and biopsy. Results: Invitation letters were sent to 1434 men. The overall study uptake was 26% (375/1436) and 87% of responders were eligible for study entry. DNA genotyping data were available for 297 men and 25 were invited for screening. After exclusions due to medical comorbidity/invitations declined, 18 of 25 men (72%) underwent MRI and biopsy of the prostate. There were seven diagnoses of PCa (38.9%). All cancers were low‐risk and were managed with active surveillance. Conclusion: The BARCODE1 Pilot has shown this community study in the UK to be feasible, with an overall uptake of 26%. The main BARCODE1 study is now open and will recruit 5000 men. The results of BARCODE1 will be important in defining the role of genetic profiling in targeted PCa population screening. Patient Summary: What is the paper about?: Very few prostate cancer screening programmes currently exist anywhere in the world. Our pilot study investigated if men in the UK would find it acceptable to have a genetic test based on a saliva sample to examine their risk of prostate cancer development. This test would guide whether men are offered prostate cancer screening tests. What does it mean for patients?: We found that the study design was acceptable: 26% of men invited to take part agreed to have the test. The majority of men who were found to have an increased genetic risk of prostate cancer underwent further tests offered (prostate MRI scan and biopsy). We have now expanded the study to enrol 5000 men. The BARCODE1 study will be important in examining whether this approach could be used for large‐scale population prostate cancer screening.

Genomic technologies are having an increasing impact across medicine, including primary care. To enable their wider adoption and realize their potential, education of primary health-care practitioners will be required. To enable the development of such resources, understanding where GPs currently access genomic information is needed. One-hundred fifty-nine UK GPs completed the survey in response to an open invitation, between September 2017 and September 2018. Questions were in response to 4 clinical genomic scenarios, with further questions exploring resources used for rare disease patients, direct-to-consumer genetic testing and collecting a family history. Respondents were most commonly GP principals (independent GPs who own their clinic) (64.8%), aged 35–49 years (54%), worked as a GP for more than 15 years (44%) and practiced within suburban locations (typically wealthier) (50.3%). The most popular ‘just in time’ education source for all clinical genomic scenarios were online primary care focussed resources with general Internet search engines also popular. For genomic continuous medical education, over 70% of respondents preferred online learning. Considering specific scenarios, local guidelines were a popular resource for the familial breast cancer scenario. A large proportion (41%) had not heard of Genomics England’s 100,000 genome project. Few respondents (4%) would access rare disease specific Internet resources (Orphanet, OMIM). Twenty-five percent of respondents were unsure how to respond to a direct-to-consumer commercial genetic test query, with 41% forwarding such queries to local genetic services. GPs require concise, relevant, primary care focussed resources in trusted and familiar online repositories of information. Inadequate genetic education of GPs could increase burden on local genetic services. Electronic supplementary material The online version of this article (10.1007/s12687-020-00457-5) contains supplementary material, which is available to authorized users.

Funder: St. George's University of London, Pharmacogenomics describes interpatient genetic variability in drug responses. Information based on whole genome sequencing will soon open up the field of pharmacogenomics and facilitate the use of genomic information relating to drug metabolism and drug responses. We undertook a qualitative study, aiming to explore the potential barriers, opportunities and challenges facing the implementation of pharmacogenomics into primary care. Semi-structured interviews were undertaken with 18 clinical participants (16 GPs and 2 other clinicians). All interviews were recorded and transcribed verbatim. Using a thematic analysis approach, data items were coded, ordered and themes constructed. Most participants were aged 55–60 years and worked as part-time clinical GPs with other clearly defined roles. The emerging themes covered several areas of concern, including the following: the utility of pharmacogenomics and the value of introducing such testing into primary care; how to educate the primary care workforce and ‘mainstream’ pharmacogenomics; the ethical, legal and social aspects of pharmacogenomics and its impact on patients; and potential impacts on the healthcare system particularly around economics and informatics. Most participants had concerns about pharmacogenomics and felt that there were a number of barriers and challenges to its implementation into routine primary care. Most striking were their concerns around the cost-effectiveness of using pharmacogenomics in primary care. At the same time most recognised the increasing availability of direct-to-consumer testing, and felt that this would drive the need to understand the ethical and social implications of using genomic information in primary care. This study has raised important issues that need to be considered when planning the implementation of pharmacogenomics into clinical practice. Prior to the implementation of genomic testing into day-to-day practice in UK primary care, it is important that considerations around education, cost-effectiveness and informatics are addressed, as well as the impact on patients.

We don’t condone unfair pressure on patients to have their flu vaccine at their general practitioner’s surgery,1 but pharmacist vaccination leads to problems with data integrity. The communication from pharmacist to general practitioner is suboptimal. It is often on paper and states only that the vaccination has occurred, without the vaccine manufacturer or batch number. In contrast to many other communications, it does not include a …

BACKGROUND: The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) comprises over 100 general practices in England, with a population of around 1 million, providing a public health surveillance system for England and data for research. AIM: To demonstrate the scope of data with the RCGP Annual Report 2014-2015 (May 2014 to April 2015) by describing disparities in the presentation of six common conditions included in the report. DESIGN AND SETTING: This is a report of respiratory and communicable disease incidence from a primary care sentinel network in England. METHOD: Incidence rates and demographic profiles are described for common cold, acute otitis media, pneumonia, influenza-like illness, herpes zoster, and scarlet fever. The impact of age, sex, ethnicity, and deprivation on the diagnosis of each condition is explored using a multivariate logistic regression. RESULTS: With the exception of herpes zoster, all conditions followed a seasonal pattern. Apart from pneumonia and scarlet fever, the odds of presenting with any of the selected conditions were greater for females (P CONCLUSION: The RCGP RSC database provides insight into the content and range of GP workload and provides insight into current public health concerns. Further research is needed to explore these disparities in presentation to primary care.

Clinicians have always personalised patient management. There is a growing momentum to improve this further through the integration of genomic information into clinical care. This will incorporate powerful new tools, through which clinicians can further tailor healthcare, improving disease prevention, prediction, diagnosis and treatment. This article aims to suggest ways in which this revolution in healthcare will affect GPs.

ObjectivesRecent evidence has highlighted the high prevalence and impact of multimorbidity, but the evidence base for improving management is limited. We have tested a new complex intervention for multimorbidity (the 3D model). The paper describes the baseline characteristics of practices and patients in order to establish the external validity of trial participants. It also explores current ‘usual primary care’ for multimorbidity, against which the 3D intervention was tested.DesignAnalysis of baseline data from patients in a cluster-randomised controlled trial and additional data from practice staff.SettingPrimary care in the UK.ParticipantsPatients with multimorbidity (n=5253) and 154 practice staff.Primary and secondary outcome measuresUsing surveys and routinely available data, we compared the characteristics of participating and non-participating practices and participating and non-participating eligible patients.Baseline questionnaire data from patient participants was used to examine participant illness burden, treatment burden and perceptions of receiving patient-centred care. We obtained data about usual care preintervention from practice staff using questionnaires and a structured pro forma.ResultsParticipating practices were slightly larger, in less deprived areas, and with slightly higher scores for patient satisfaction compared with non-participating practices. Patients with dementia or learning difficulties were likely to be excluded by their general practitioners, but comparison of participants with non-participants identified only minor differences in characteristics, suggesting that the sample was otherwise representative. Patients reported substantial illness burden, and an important minority reported high treatment burden. Although patients reported relatively high levels of satisfaction with care, many reported not having received potentially important components of care.ConclusionThis trial achieved good levels of external validity. Although patients were generally satisfied with primary care services, there was significant room for improvement in important aspects of care for multimorbidity that are targeted by the 3D intervention.Trial registration numberISRCTN06180958; Post-results.

Increasingly, genomic data are being used for the diagnosis and treatment of disease, and in due course could be used for the prevention of disease.1 Following multiple endorsements of genomic medicine in 2018, UK Secretary of State for Health and Social Care, Matt Hancock, announced in January 2019 the development of a direct-to-consumer service for whole-genome sequencing, with provision for ‘customers’ to donate their data for research purposes.2 We present a dissensus — arguments why UK primary care should, and why it should not, be an early adopter of this technology, in order to understand its ethical aspects. Genomic medicine is already with us in the NHS. The 100 000 Genome Project (https://www.genomicsengland.co.uk/) has generated regional genomic medical centres, which will help in determining the clinical utility of gene variants. We already have genomic databases that aim to link genotype with phenotype. Anyone in the UK, including patients and their families, can pay for an over-the-counter genetic test that provides information on long-term conditions, such as asthma or hypertension, as well as information about personal traits. There is a duty to respond to their needs for knowledge, and consider targeted treatments and avoidance of potentially harmful treatments that are unlikely to work. We have to understand the opportunities and limitations presented by patients turning up with genomic information to discuss, and GPs will identify learning needs as a result of exposure to genomic conversations with patients. By definition, the genomic patient has acquired a disorder through no fault of their own but by reason of being born. …

Background: Living in a conurbation, urban, or rural environment is an important determinant of health. For example, conurbation and rural living is associated with increased respiratory and allergic conditions, whereas a farm or rural upbringing has been shown to be a protective factor against this. Objective: The objective of the study was to assess differences in general practice presentations of allergic and infectious disease in those exposed to conurbation or urban living compared with rural environments. Methods: The population was a nationally representative sample of 175 English general practices covering a population of over 1.6 million patients registered with sentinel network general practices. General practice presentation rates per 100,000 population were reported for allergic rhinitis, asthma, and infectious conditions grouped into upper and lower respiratory tract infections, urinary tract infection, and acute gastroenteritis by the UK Office for National Statistics urban-rural category. We used multivariate logistic regression adjusting for age, sex, ethnicity, deprivation, comorbidities, and smoking status, reporting odds ratios (ORs) with 95% CIs. Results: For allergic rhinitis, the OR was 1.13 (95% CI 1.04-1.23; P=.003) for urban and 1.29 (95% CI 1.19-1.41; P Conclusions: Those living in conurbations or urban areas were more likely to consult a general practice for allergic rhinitis and upper respiratory tract infection. Both conurbation and rural living were associated with an increased risk of urinary tract infection. Living in rural areas was associated with an increased risk of asthma and lower respiratory tract infections. The data suggest that living environment may affect rates of consultations for certain conditions. Longitudinal analyses of these data would be useful in providing insights into important determinants.

BACKGROUND Living in a conurbation, urban, or rural environment is an important determinant of health. For example, conurbation and rural living is associated with increased respiratory and allergic conditions, whereas a farm or rural upbringing has been shown to be a protective factor against this. OBJECTIVE The objective of the study was to assess differences in general practice presentations of allergic and infectious disease in those exposed to conurbation or urban living compared with rural environments. METHODS The population was a nationally representative sample of 175 English general practices covering a population of over 1.6 million patients registered with sentinel network general practices. General practice presentation rates per 100,000 population were reported for allergic rhinitis, asthma, and infectious conditions grouped into upper and lower respiratory tract infections, urinary tract infection, and acute gastroenteritis by the UK Office for National Statistics urban-rural category. We used multivariate logistic regression adjusting for age, sex, ethnicity, deprivation, comorbidities, and smoking status, reporting odds ratios (ORs) with 95% CIs. RESULTS For allergic rhinitis, the OR was 1.13 (95% CI 1.04-1.23; P=.003) for urban and 1.29 (95% CI 1.19-1.41; P CONCLUSIONS Those living in conurbations or urban areas were more likely to consult a general practice for allergic rhinitis and upper respiratory tract infection. Both conurbation and rural living were associated with an increased risk of urinary tract infection. Living in rural areas was associated with an increased risk of asthma and lower respiratory tract infections. The data suggest that living environment may affect rates of consultations for certain conditions. Longitudinal analyses of these data would be useful in providing insights into important determinants.

Hypothyroidism is common in women of reproductive age and occurs in 2–3% of all pregnancies.1,2 Suboptimal thyroid function in pregnancy carries significant risks of poor obstetric outcomes including pregnancy loss and offspring neurodevelopmental impairment.2 These outcomes could potentially be improved through preconception care targeted at women of reproductive age with hypothyroidism. Most women with hypothyroidism are managed in general practice, and facilities for annual thyroid monitoring, medication reviews, and the maintenance of hypothyroidism disease registers, are available within existing primary care resources. In addition, the vast majority of women with hypothyroidism who become pregnant have pre-existing thyroid disease and are already established on treatment by the time of conception. Thus, opportunities abound in general practice to optimise thyroid hormone replacement and prepare women with thyroid dysfunction for conception. In this editorial, the authors discuss the challenges of preconception management of hypothyroidism and highlight current recommendations and a new patient education resource. Thyroid hormones are essential for normal fetal growth and development.2 The devastating neurological consequences of severe iodine deficiency or neglected congenital hypothyroidism in children are now thankfully rare but remain grim reminders of the importance of thyroid hormones for fetal development. More subtle effects of thyroid hormone deficiency are widespread. Landmark studies in the 1990s showed that children born to women with uncorrected hypothyroidism during pregnancy had a 7-point IQ deficit compared to children of euthyroid mothers.3 Since then, numerous observational studies have shown increased risks of pregnancy loss and child neuro-intellectual impairment in untreated, as well as suboptimally treated, women with hypothyroidism.2,4 An adequate supply of thyroid hormones is particularly important in early gestation as the fetus cannot synthesise thyroid hormones until the second trimester, and before this time, relies …

Background Recording concerns about child maltreatment, including minor concerns, is recommended by the General Medical Council (GMC) and National Institute for Health and Clinical Excellence (NICE) but there is evidence of substantial under-recording.Aim To determine whether a simple coding strategy improved recording of maltreatment-related concerns in electronic primary care records.Design and Setting Clinical audit of rates of maltreatment-related coding before January 2010–December 2011 and after January–December 2012 implementation of a simple coding strategy in 11 English family practices. The strategy included encouraging general practitioners to use, always and as a minimum, the Read code ‘Child is cause for concern’. A total of 25,106 children aged 0–18 years were registered with these practices. We also undertook a qualitative service evaluation to investigate barriers to recording.Method Outcomes were recording of 1) any maltreatment-related codes, 2) child protection proceedings and 3) child was a cause for concern.Results We found increased recording of any maltreatment-related code (rate ratio 1.4; 95% CI 1.1–1.6), child protection procedures (RR 1.4; 95% CI 1.1–1.6) and cause for concern (RR 2.5; 95% CI 1.8–3.4) after implementation of the coding strategy. Clinicians cited the simplicity of the coding strategy as the most important factor assisting implementation.Conclusion This simple coding strategy improved clinician’s recording of maltreatment-related concerns in a small sample of practices with some ‘buy-in’. Further research should investigate how recording can best support the doctor–patient relationshipHow this fits in Recording concerns about child maltreatment, including minor concerns, is recommended by the General Medical Council (GMC) and National Institute for Health and Clinical Excellence (NICE), but there is evidence of substantial underrecording. We describe a simple clinical coding strategy that helped general practitioners to improve recording of maltreatment-related concerns. These improvements could improve case finding of children at risk and information sharing.

BACKGROUND The Royal College of General Practitioners Research and Surveillance Centre comprises more than 150 general practices, with a combined population of more than 1.5 million, contributing to UK and European public health surveillance and research. OBJECTIVE The aim of this paper was to report gender differences in the presentation of infectious and respiratory conditions in children and young adults. METHODS Disease incidence data were used to test the hypothesis that boys up to puberty present more with lower respiratory tract infection (LRTI) and asthma. Incidence rates were reported for infectious conditions in children and young adults by gender. We controlled for ethnicity, deprivation, and consultation rates. We report odds ratios (OR) with 95% CI, P values, and probability of presenting. RESULTS Boys presented more with LRTI, largely due to acute bronchitis. The OR of males consulting was greater across the youngest 3 age bands (OR 1.59, 95% CI 1.35-1.87; OR 1.13, 95% CI 1.05-1.21; OR 1.20, 95% CI 1.09-1.32). Allergic rhinitis and asthma had a higher OR of presenting in boys aged 5 to 14 years (OR 1.52, 95% CI 1.37-1.68; OR 1.31, 95% CI 1.17-1.48). Upper respiratory tract infection (URTI) and urinary tract infection (UTI) had lower odds of presenting in boys, especially those older than 15 years. The probability of presenting showed different patterns for LRTI, URTI, and atopic conditions. CONCLUSIONS Boys younger than 15 years have greater odds of presenting with LRTI and atopic conditions, whereas girls may present more with URTI and UTI. These differences may provide insights into disease mechanisms and for health service planning.

In 2014, the National Institute for Health Care Excellence (NICE) changed its guidelines for offering statins to patients, reducing the threshold from 20% cardiovascular risk to 10%.1 This ignited a fervent debate about the wisdom and practicality of the change and raised three key questions: Do we really have the right evidence on which to make a decision about the risk/benefit balance? Is that evidence trustworthy when applied to patients seen in general practice? How can we communicate the best possible evidence to the people who need to make the relevant decisions: policy makers, clinicians, and the public? These questions are not, of course, specific to the issue of statins; they go to the heart of how healthcare decisions are made and as a result were the trigger for a request from the Chief Medical Officer of England to the Academy of Medical Sciences (AMS) to examine the issues in detail. The resulting report was finally published last month.2 The report presents 12 recommendations (Box 1) that are planned to address nothing less than the scientific basis of medicine: from deciding how research efforts should be targeted, to guidelines for science reporting in the media; from improving the methodology of clinical trials to the design of patient information leaflets. But what does it mean for GPs? Box 1: ### The 12 recommendations Ensuring evidence is robust and relevant

What you need to know A 65 year old obese man with diabetes, hypertension, osteoarthritis, and a two month history of persistent lower urinary tract symptoms attended his general practice with general malaise. Regular medications included metformin, gliclazide, ramipril, and ibuprofen. On examination, his blood pressure was 150/96 mm Hg. Digital rectal examination revealed a smooth enlarged prostate. Urine analysis showed 2+ proteinuria. Blood tests revealed a serum creatinine concentration of 160 µmol/L, compared with 78 µmol/L three weeks earlier; his prostate specific antigen (PSA) level had been 6 µg/L. Acute kidney injury (AKI) is a syndrome characterised by a sudden decline in renal function. To standardise AKI classification, international guidelines were published in 2012 (table 1).1 View this table: Table 1 KDIGO classification of acute kidney injury (AKI)1 Population incidence of AKI is as high as 0.2%,2 and between 8.4% and 17.6% among hospital inpatients.34 Around two thirds of AKI cases identified in hospital develop in the community before hospitalisation.5 AKI is associated with longer inpatient admissions, increased risk of progression to chronic kidney disease (CKD), and higher mortality (in hospital6 and long term).37 Prompt identification of AKI and early management initiated in primary care is central to improving outcomes. AKI in the community is most commonly due to infections such as influenza or gastroenteritis, with associated fluid depletion.8 …

BackgroundTelehealth care and telephone consultations are increasingly used in primary care for daily triage, patient reviews, and providing clinical information; however little is known about the perceptions of GP trainees.AimTo investigate the knowledge and skills of GP trainees in conducting telephone consultations; evaluate their current experiences and learning needs; and identify future training considerations based on feedback received.MethodUsing a mixed-methods approach, a cross-sectional quantitative survey of North Central and East London (NCEL) GP trainees was initially performed. This was followed-up by qualitative semi-structured interviews, which allowed deeper exploration of themes.ResultsIn total 100 trainees responded to the survey, and eight proceeded with interviews. Trainees were least confident in independently undertaking more complex aspects of telephone consulting, and there was a positive correlation between training received and confidence to work independently. Despite positive and negative experiences, trainees felt that there were gaps in their training and significant differences in overall confidence, supervision and feedback among different training grades and between in-hours and out-of-hours practice. Future considerations included curricular promotion, increased trainer-trainee observations using audio-clinical observation tools or simulated practice, and consideration of formal training.ConclusionThis project has shed light on the current learning, feedback, and assessment practices of GP trainees in conducting telephone consultations. Further evaluation will provide a helpful guide to various stakeholders, foresee any challenges and inform a wider debate among postgraduate learners regarding their training for the use of technology in healthcare.

BackgroundRapidly undertaken age-stratified serology studies can produce valuable data about a new emerging infection including background population immunity and seroincidence during an influenza pandemic. Traditionally seroepidemiology studies have used surplus laboratory sera with little or no clinical information or have been expensive detailed population based studies. We propose collecting population based sera from the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), a sentinel network with extensive clinical data.AimTo pilot a mechanism to undertake population based surveys that collect serological specimens and associated patient data to measure seropositivity and seroincidence due to seasonal influenza, and create a population based serology bank.Methods and analysisSetting and Participants: We will recruit 6 RCGP RSC practices already taking nasopharyngeal virology swabs. Patients who attend a scheduled blood test will be consented to donate additional blood samples. Approximately 100–150 blood samples will be collected from each of the following age bands – 18– 29, 30– 39, 40– 49, 50– 59, 60– 69 and 70+ years.MethodsWe will send the samples to the Public Health England (PHE) Seroepidemiology Unit for processing and storage. These samples will be tested for influenza antibodies, using haemagglutination inhibition assays. Serology results will be pseudonymised, sent to the RCGP RSC and combined using existing processes at the RCGP RSC secure hub. The influenza seroprevalence results from the RCGP cohort will be compared against those from the annual PHE influenza residual serosurvey.Ethics and disseminationEthical approval was granted by the Proportionate Review Sub- Committee of the London – Camden & Kings Cross on 6 February 2018. This study received approval from Health Research Authority on 7 February 2018. On completion the results will be made available via peer-reviewed journals.

Strict control of systolic blood pressure is known to slow progression of chronic kidney disease (CKD). Here we compared audit-based education (ABE) to guidelines and prompts or usual practice in lowering systolic blood pressure in people with CKD. This 2-year cluster randomized trial included 93 volunteer general practices randomized into three arms with 30 ABE practices, 32 with guidelines and prompts, and 31 usual practices. An intervention effect on the primary outcome, systolic blood pressure, was calculated using a multilevel model to predict changes after the intervention. The prevalence of CKD was 7.29% (41,183 of 565,016 patients) with all cardiovascular comorbidities more common in those with CKD. Our models showed that the systolic blood pressure was significantly lowered by 2.41 mm Hg (CI 0.59–4.29 mm Hg), in the ABE practices with an odds ratio of achieving at least a 5 mm Hg reduction in systolic blood pressure of 1.24 (CI 1.05–1.45). Practices exposed to guidelines and prompts produced no significant change compared to usual practice. Male gender, ABE, ischemic heart disease, and congestive heart failure were independently associated with a greater lowering of systolic blood pressure but the converse applied to hypertension and age over 75 years. There were no reports of harm. Thus, individuals receiving ABE are more likely to achieve a lower blood pressure than those receiving only usual practice. The findings should be interpreted with caution due to the wide confidence intervals.

The recent report by the National Data Guardian for Health and Care (or ‘Caldicott 3’) reviewed NHS data security, consent, and opt-outs for patients.1 At the same time the Care Quality Commission (CQC) was also asked to review current approaches to data security across the NHS.2 As soon as both reports were published, care.data (NHS England’s controversial data-sharing programme) was immediately closed down.3 There is little doubt that the use of large-scale health data has considerable potential to benefit not only patient care but also public health and research.4 The use of such data, however, raises great concerns about data security, patient privacy, and probably most importantly public trust, not only in the NHS but also in the relationship with their doctor. The demise of care.data was in no small part due to a loss of public trust and Caldicott 3 demands increased dialogue with the public to restore their trust. The NHS and GPs in particular, must be ‘beyond reproach’ in their use of health data to improve both direct and indirect patient care as well as contributions to public health and health research. Dame Fiona Caldicott’s review follows her previous reviews in 1996/1997 and 2013. The first of her reviews recommended six principles for the protection of people’s confidentiality (the Caldicott principles) and the second recommended an additional Caldicott principle which stated that duty to share information can be just as important as the duty to protect patient confidentiality. Caldicott 3 addresses the further issue of data security and future models of consent. As far as data security is concerned, the new Caldicott report sets out 10 standards which need to be applied in every healthcare organisation to address the three causes of data breaches: people, processes, and technology. As a way of improving …

Background: Improving understanding of the genetic basis of disease susceptibility enables us to estimate individuals' risk of developing cancer and offer them disease prevention, including screening, stratified to reflect that risk. Little attention has so far been given to the implementation of stratified screening. This article reviews the issues that would arise in delivering such tailored approaches to prevention in practice. Results: Issues analysed include the organisational context within which implementation of stratified prevention would occur, how the offer of screening would be made, making sure consent is adequately informed, how individuals' risk would be assessed, the age at which risk estimation should occur, and the potential use of genetic data for other purposes. The review also considers how management might differ depending on individuals' risk, how their results would be communicated and their follow-up arranged, and the different issues raised by modification of an existing screening programme, such as that for breast cancer, and the establishment of a new one, for example for prostate cancer. Conclusion: Stratified screening based on genetic testing is a radically new approach to prevention. Various organisational issues would need to be considered before it could be introduced, and a number of questions require further research.

> ‘When you hear hoofbeats, don’t expect to see a Zebra. ’1 The above adage is especially useful in primary care as many of the conditions we see are common. But it is not so useful when we consider our role in both diagnosing and supporting patients with rare diseases. We must be ready to think again and look out for the horse with stripes. A rare disease is defined by an incidence of