General practice workload is increasing. Routinely reported NHS data describes workload in relation to numbers of appointments and clinicians delivering appointments. However, "hidden" aspects of general practice workload, such as administrative and supervisory tasks, are not measured. The Hidden Workload Study will examine the full range of tasks that general practice clinicians undertake daily and investigate how workload varies according to clinical role and practice demographics. Participants' lived experience of workload will also be explored through interviews. Utilising the Primary Care Academic CollaboraTive's membership and collaborative methodology, mixed quantitative and qualitative methods will be used. All clinicians working in English general practice, including general practitioners of all grades, resident doctors, nurses, physician associates, pharmacists and other allied healthcare professionals will be eligible, aiming for>500 participants across>75 practices. Participants will collect data on a randomly allocated day in late 2024/early 2025. Using a data collection form and timers, participants will record their planned work schedule and then all tasks they complete, including all clinical, administrative, and supervisory tasks, and breaks. Practice demographic data will be collected from NHS Fingertips. For the qualitative arm, 15-20 semi-structured qualitative interviews will also be carried out. Quantitative data will be described according to clinical role and practice demographics, and interviews transcribed and reflexively analysed. The Hidden Workload Study will provide a comprehensive mixed methods analysis of contemporary general practice workload. Potential explanations for workload variations will be explored, informing future service provision and workforce planning.

Over the past decade, remote (non-face-to-face) services - including interactions via the telephone and online platforms - have been increasingly used in primary care. These services bring potential benefits, as well as potential barriers, for patients. Older migrants are a population that could face intersectional barriers when accessing health care; it is important to understand the impact of remote services on them. This study explores older Chinese migrants' experiences of, and attitudes to, remote access to primary care services. A qualitative semi-structured interview study. Recruitment was carried out in 2023, through community organisations, social media, and snowballing. Participants were individuals aged ≥60 years, who self-identified ethnically as Chinese, and were UK residents; they were purposively sampled for maximum variation in sociodemographics and backgrounds. Data were collected through semi-structured interviews conducted in English and Mandarin. Interviews were recorded and transcribed verbatim; if consent to record the interview had not been given, field notes were taken. Transcripts and field notes were analysed using reflexive thematic analysis. Results were shared with participants for verification. Nineteen participants were interviewed. Many technical and practical barriers were reported as existing for the participants when accessing primary care remotely. Due to the different levels of access to resources, these barriers affected the most disadvantaged people to the greatest degree. In addition, participants felt the need for in-person interactions to address some concerns and believed remote services should not replace in-person care. Overall, older Chinese migrants felt few benefits from using remote primary care services. In the current digital context of the NHS, it is crucial to keep multimodal services available while rolling out new service modes, and to consider the needs of different populations to ensure equitable access.

Early chronic obstructive pulmonary disease (COPD) diagnosis is vital, but little is known about compliance with relevant diagnostic guidelines or variation in primary care. To quantify between-practice variations in guideline compliance and over time. An observational study in English primary care. The Clinical Practice Research Datalink was used to assess the use of four pre-diagnostic investigations (spirometry, chest X-ray, full blood count [FBC], and body mass index [BMI]) by GP practices for patients with COPD recorded first in primary care, in three time periods: 2006-2007 (cohort 1), 2016-2017 (cohort 2), and March-August 2020 (cohort 3). Multilevel logistic regression models quantified the non-random variation between GP practices in spirometry around diagnosis. Funnel plots counted the proportion of outliers. Cohort totals were 31 676 (cohort 1), 37 393 (cohort 2), and 3368 (cohort 3). Overall, the mean age was 68.3 years (standard deviation 12.0), with 46.1% female. The use of pre-diagnosis spirometry improved a little in cohort 2 (74.2%) on cohort 1 (62.8%) but fell back for the COVID-19-era group (61.1%). In contrast, chest X-ray, FBC, and BMI all improved after cohort 1 and were maintained for the COVID-19 cohort; almost all patients received one of these investigations. The proportion receiving all four investigations before diagnosis jumped from 26.6% in cohort 1 to 46.7% in cohort 2 and was maintained in cohort 3 (43.0%). Modelling and funnel plots showed considerable non-random variation in spirometry use by practice, although with some improvement since cohort 1. The recording of spirometry and chest X-rays warrants further and consistent improvement in the context of COPD care.

Collaborative working between GPs and community pharmacists (CPs) has led to improvements in management of long-term conditions, and has strong policy backing, yet such joint working remains patchy and underdeveloped. Understanding the perspectives of GPs and CPs regarding collaboration provides insights for more sustainable collaborative practices. To understand the perspectives of GPs and CPs concerning collaborative care practices, and to develop a framework of factors that influence this collaborative working relationship. A systematic review of qualitative studies. Five databases were searched from inception to the 22 April 2023 for qualitative studies exploring GP and CP views on collaborative care services. Articles were independently screened by two reviewers at title, abstract, and full-text levels. Data extracted from eligible studies were analysed and synthesised thematically. Thirty-six studies met the inclusion criteria. The following four main themes were identified: (1) how pre-existing relationships influence mutual understanding of roles; (2) the impact of co-location and communication on relationship building; (3) analysis of perceived costs and benefits of collaborative care; and (4) unequal motivation to collaborate. A complex interplay of factors influences GP and CP collaborative working, including pre-existing relationships, communication and mutual understanding, and the balance of costs and benefits to further develop these relationships. When planning future collaborative care practices, stakeholders must take the time and initiative to elucidate and understand these factors within their own unique healthcare setting to form lasting working relationships.

UK COVID-19 lockdowns significantly affected primary care access and delivery. Little is known about whether lockdowns disproportionally impacted vulnerable groups, including people who misuse substances, people who have experienced domestic violence or abuse, those with intellectual disability, and children with safeguarding concerns. To evaluate the impact of UK COVID-19 lockdowns on primary care contact rates among vulnerable groups. Natural experimental design using all registered patients in the OpenSAFELY platform. With approval from NHS England, we conducted controlled interrupted time-series analyses on records from 24 million patients in England between September 2019 and September 2021. Pre-pandemic, primary care contact rates were 110.1 per 1000 patients per week. Following the initiation of the first lockdown (23 March 2020), there was a large reduction of 29-61 contacts per 1000 patients per week among vulnerable and general population groups. For patients with alcohol misuse, those aged ≥14 years with intellectual disability, and children with safeguarding concerns, this reduction was significantly more extreme than corresponding general populations (relative rate difference -23.8 [95% confidence interval {CI} = -39.8 to -7.7, P = 0.003], -24.6 [95% CI = -38.8 to -10.5, P<0.001], and -15.4 [95% CI = -26.9 to -3.8, P = 0.009], respectively). Following the final lockdown (29 March 2021), all groups had contact rates exceeding pre-pandemic rates (with increases more marked in vulnerable populations), except those only including children. Our results suggested a larger short-term impact of the first COVID-19 lockdown on primary care contact for some vulnerable groups, compared with the general population, and differential impacts persisted through subsequent lockdowns and beyond for some vulnerable groups. There is a need to examine drivers of these differences to enable more equitable primary care access and provision.

Socioeconomic deprivation is associated with lower life expectancy and more complex health needs. General practices may mitigate some of these health impacts by providing holistic care to their patients. The Deep End network was established in 2009 in Scotland to support practices working in the most socioeconomically deprived communities, and the concept has since spread, with Deep End Wales (Cymru) launching in 2022. To explore experiences of staff working within Deep End practices in Wales and understand their motivations for choosing to work in challenging practices along with their needs from a Deep End network. Qualitative study with staff from Deep End eligible practices in Wales. Seventeen semi-structured interviews were undertaken. Data were analysed using thematic analysis and interpreted with reference to self-determination theory. The following four main themes were identified: (1) Treading water (experiences of providing care in Deep End practices); (2) Diving into the Deep End (motivations for working in a Deep End practice); (3) Providing a life jacket (support from the Deep End Cymru community); and (4) Swimming to shore (the search for work-based effectiveness). Deep End staff reported high workload, with limited resources and time to manage complex health needs. Most participants found working in Deep End practices rewarding. However, there were concerns about staff burnout, recruitment, and retention of staff. Deep End Cymru is providing hope, validation, and a place to share ideas. Barriers to success were funding and time. Participants want Deep End Cymru to advocate for them, support recruitment, improve services for patients, and support research.

The UK healthcare system has a growing workforce crisis, which is felt especially acutely in primary care. A prospective solution is the use of physician associates (PAs). In recent times, this has generated some controversy. There is a sparsity of synthesised evidence around the use of PAs in the UK, particularly their implementation in primary care. To look at the impact PAs have on workload, safety, efficacy, and cost-effectiveness in delivering UK primary care. Systematic review of peer-reviewed literature, including qualitative and quantitative studies of PAs, in UK primary care. Cochrane and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. PubMed, Embase, the Cochrane Library, Web of Science, and CINAHL were searched from 2011-2024. Covidence was used for data management. Narrative synthesis was performed based on the four primary aims. Sixteen studies were deemed to meet the inclusion criteria for data extraction and synthesis. Thirteen commented on workload, eight commented on safety, 13 on efficacy, and eight studies discussed cost-effectiveness. Results showed that PAs were considered clinically safe but impacts on workload and efficacy were less clear. Cost-effectiveness assessment was limited by inability to calculate full costs or benefits. This review found that there is limited evidence available in the published literature to demonstrate the impact of PAs in primary care. While there were some positive studies, a clear need for further research was demonstrated. An additional pathway to explore, comparing PAs with the non-GP primary care workforce, was also noted.

Health care contributes substantially to climate change. GPs want to implement sustainable health care but are hesitant, worried that this may jeopardise their doctor-patient relationship. However, whether this concern is valid should be urgently assessed. To explore patients' perspectives on sustainable health care in general practice. In 2022 and 2023, we performed an online study with Dutch adults using experimental vignettes and a questionnaire. The vignettes described GP appointments for three health complaints with randomly allocated treatment advice, varying in sustainability and explanation, but with comparable health outcomes. The questionnaire assessed participants' perspectives on sustainable health care in general practice. We analysed the vignettes using mixed-design analysis of variance (ANOVA) and the questionnaire using descriptive statistics and correlations. In total, 801 participants completed the vignettes, and 397 the questionnaire. We found no difference on satisfaction with a doctor's visit (P values >0.24) when comparing a sustainable and a less-sustainable treatment option. The effect of explicitly mentioning sustainability differed per health complaint (dyspnoea: no difference; knee pain: mean difference [MD] = 0.31, P = 0.002; erythema: MD = -0.23, P = 0.003). In the questionnaire, participants reported positive expectations, and trust in the GP and treatment when delivering sustainable health care, but were more neutral about the GP's role. We found no indication that sustainable treatment advice leads to lower satisfaction with GP care. The effect of explicitly mentioning sustainability was minimal and differed per health complaint. When directly asked, participants were mainly positive about sustainable health care. These results could encourage GPs to introduce sustainable treatment advice, without worrying about negatively influencing patient satisfaction.

Acetylcholinesterase inhibitors (AChEIs) are routinely prescribed for mild-to-moderate Alzheimer's disease (AD). National guidance advises GPs to initiate memantine for patients already taking an AChEI, as it offers small benefits for moderate-to-severe AD, with good tolerability. But this is not routinely done, potentially depriving patients of a beneficial treatment. To assess prescribing for AD in general practice, to explore factors influencing prescribing, and to identify additional education needs. Mixed-methods study involving GPs in England. An online survey and semi-structured interviews were conducted. Survey responses were analysed in StataNow (version 18.5). Interview transcriptions were coded in NVivo (version 14) by two researchers, who agreed themes. Quantitative and qualitative analyses were integrated and mapped to the Theoretical Domains Framework (TDF) and behaviour change wheel (BCW). Survey responders (n = 104) mostly continued rather than initiated memantine. Less than half were confident in identifying AD stages and developing care plans for moderate-to-severe AD. Overall, 46% of responders were unaware of current national guidance concerning memantine. Interviews (n = 23) mostly concurred with survey findings. Direction from local formularies conflicts with current national guidance. Mapping to TDF and BCW identified barriers to, facilitators, and interventions for changing practice. Limited time, patchy support, and Quality and Outcomes Framework downgrading contribute to a perception that dementia is not prioritised in general practice. Local systems for diagnosis and treatment reinforce GPs' feelings of inadequacy. GPs assess the impact of AD on patients and families but may not map assessments to a disease stage for memantine initiation. Interventions to change practice should boost knowledge and confidence; local pathways should clearly reflect national guidance.

Green social prescribing (GSP) aims to link patients to nature-based health interventions (NBHIs) through GPs. However, knowledge of GPs' views on GSP is limited. To explore GPs' views on GSP and the factors influencing these views. National cross-sectional survey of GPs' working lives in Scotland, conducted in 2023, which included four questions about GSP. Descriptive analysis of GPs' views of GSP and univariate and multivariate (binary logistic) analysis of factors influencing these views. The survey found 79.6% (n = 1098) of GPs had heard of GSP, 81.3% (n = 1106) would be happy to refer patients to NBHIs, 67.8% (n = 931) thought GSP was suitable for older patients with multimorbidity, and 43.7% (n = 599) felt that patients living in deprived areas would access GSP. Greater knowledge of GSP was associated with White ethnicity (adjusted odds ratio [aOR] 2.04; 95% confidence interval [CI] = 1.30 to 3.22, P = 0.002) and the number of clinical sessions worked per week (aOR 0.90; 95% CI = 0.82 to 0.99, P = 0.034). Higher job satisfaction was associated with more positive views about the suitability of GSP for older patients with multimorbidity (aOR 1.14; 95% CI = 1.00 to 1.30; P = 0.043) as were views on whether patients living in deprived areas would access GSP (aOR 1.20; 95% CI = 1.03 to 1.33, P = 0.013). GPs working in deprived areas also had more positive views regarding whether patients living in deprived areas would access GSP (aOR 1.24; 95% CI = 1.06 to 1.45, P = 0.159). GPs in Scotland are aware of and willing to refer to GSP but have concerns about accessibility for patients from deprived areas. Views were influenced by personal and practice characteristics.