BackgroundSocial prescribing involving primary care-based ‘link workers’ is a key UK health policy that aims to reduce health inequalities. However, the process of implementation of the link worker approach has received little attention despite this being central to the desired impact and outcomes.AimTo explore the implementation process of such an approach in practice.Design and settingQualitative process evaluation of the ‘Deep End’ Links Worker Programme (LWP) over a 2-year period, in seven general practices in deprived areas of Glasgow.MethodThe study used thematic analysis to identify the extent of LWP integration in each practice and the key factors associated with implementation. Analysis was informed by normalisation process theory (NPT).ResultsOnly three of the seven practices fully integrated the LWP into routine practice within 2 years, based on the NPT constructs of coherence, cognitive participation, and collective action. Compared with ‘partially integrated practices’, ‘fully integrated practices’ had better shared understanding of the programme among staff, higher staff engagement with the LWP, and were implementing all aspects of the LWP at patient, practice, and community levels of intervention. Successful implementation was associated with GP buy-in, collaborative leadership, good team dynamics, link worker support, and the absence of competing innovations.ConclusionEven in a well-resourced government-funded programme, the majority of practices involved had not fully integrated the LWP within the first 2 years. Implementing social prescribing and link workers within primary care at scale is unlikely to be a ‘quick fix’ for mitigating health inequalities in deprived areas.

BackgroundPrimary care has a crucial role in responding to the COVID-19 pandemic as the first point of patient care and gatekeeper to secondary care. Qualitative studies exploring the experiences of healthcare professionals during the COVID-19 pandemic have mainly focused on secondary care.AimTo gain an understanding of the experiences of European primary care professionals (PCPs) working during the first peak of the COVID-19 pandemic.Design and settingAn exploratory qualitative study, using semi-structured interviews in primary care in England, Belgium, the Netherlands, Ireland, Germany, Poland, Greece, and Sweden, between April and July 2020.MethodInterviews were audiorecorded, transcribed, and analysed using a combination of inductive and deductive thematic analysis techniques.ResultsEighty interviews were conducted with PCPs. PCPs had to make their own decisions on how to rapidly transform services in relation to COVID-19 and non-COVID-19 care. Despite being overwhelmed with guidance, they often lacked access to practical training. Consequently, PCPs turned to their colleagues for moral support and information to try to quickly adjust to new ways of working, including remote care, and to deal with uncertainty.ConclusionPCPs rapidly transformed primary care delivery despite a number of challenges. Representation of primary care at policy level and engagement with local primary care champions are needed to facilitate easy and coordinated access to practical information on how to adapt services, ongoing training, and access to appropriate mental health support services for PCPs. Preservation of autonomy and responsiveness of primary care are critical to preserve the ability for rapid transformation in any future crisis of care delivery.

The day had been unusually tough. Monday morning on-call had included the cataclysmic event of a patient calling to report finding her husband had taken his own life. She was having a panic attack and reception had put through the call as urgent. The story ached with poignancy and pain and the grief being expressed was visceral. And there was other stuff lurking in the back of my mind; a patient complaint, a coroner’s report to write. My shoulders and lower back were getting ever more tense and my brain tired; the day was long. Thirteen hours after leaving the house that morning I was back home and frazzled. I needed to eat, connect with my family, and prepare for the next day. But first, the daily, evening ritual of watering the plants in the newly acquired greenhouse; a happier consequence of COVID-19’s devastation on our lives when long haul holidays evaporated and staycations became the new norm. I am a newbie to this world of growing and greenery but as I opened the door in the gloaming evening light the air in the greenhouse felt softer and I started to feel my adrenergic drive subside. The gentle activity of watering the plants and flowers and observing the small changes from the previous day brought a welcome calming effect and a lightening of mood. My pulse slowed down and shoulders relaxed. The liminal space of the glasshouse seemed to offer a tangible benefit. Could pottering in the greenhouse really mitigate against the toxic impact of work-related stress on our brains? There is no mistaking the pressure our profession is under. Even before the emergence of COVID-19 we were sinking. The 2019 GMC report, Caring for Doctors, Caring for Patients , shows GPs reporting the lowest levels of job satisfaction and …

We note the concerns expressed by Abdel Shaheed et al in their recent editorial ‘Drugs for Chronic Pain’.1 They expressed important anxieties about the availability of pharmacological options for GPs treating chronic pain, which will be restricted if the current draft National Institute for Health and Care Excellence (NICE) guideline is implemented.2 Their concerns include: As clinicians treating chronic pain, people living with chronic pain, and advisors on relevant national policy, we share these concerns, and add the following observations: 1. Lack of evidence of effectiveness at population level does not equate to lack of effectiveness for all individuals. As Andrew Moore …

It was with great hope for a better 2021 that we ended last year having heard the news of effective vaccines for COVID-19. We will never forget the year of lockdowns, thousands of lives lost, and fears of overburdening the NHS. Sadly, we had to go into another lockdown in England for the start of the new year, as COVID-19 infection rates continued to rise. It became a race between vaccinations and rates of infection during the third lockdown. A plan to first vaccinate the most vulnerable and exposed was drawn up, with the availability of vaccines being the main rate-limiting factor. Interestingly, there are different attitudes to the vaccine, especially among Black, Asian and minority ethnic (BAME) groups, which have affected uptake. Conspiracy theories about the new vaccines were being spread on WhatsApp and social media sites, raising questions about possible unknown side-effects and ulterior motives. As a GP, I have the privilege of prompt access to a COVID-19 vaccination and vaccine training as a vaccinator, and nothing I have read or seen so far has given me unusual cause for concern about the vaccine, but I am interested in a possible ‘side effect’ of the release of this vaccine that we may not have discussed …

There are 1250 primary care networks (PCNs) in the English NHS. Established in July 2019, PCNs have been developed in response to national policy focused on better integrating health and social care services while strengthening the sustainability of primary care.1 They receive additional funding to support the employment of new types of practitioners and provide enhanced services to patients. While originally intended to cover populations of 30 000 to 50 000 patients, only 58% of PCNs are within this range, with some smaller, and more that are larger.2 Research into the implementation and early development of PCNs suggests swift and impressive progress compared with some of their antecedent primary care organisations, with initial governance arrangements in place, and staff recruited to deliver practice-based pharmacy, social prescribing, and enhanced support for care homes.3 PCNs are also playing an important role in primary care responses to the pandemic3 and the COVID-19 vaccination programme.4 This seemingly positive and striking early progress conceals a profound organisational fragility that emerged as an important theme in the two National Institute for Health Research funded studies of PCNs. …

Fifty years since the term was first used to describe the mismatch between healthcare provision and healthcare need,1 the inverse care law is alive and well. Coined by Julian Tudor Hart, a GP in a coal-mining community in south Wales, the term was a clever pun on the inverse square law. And it has stuck ever since. Although primary care in 2021 has changed beyond recognition since 1971, one factor remains largely unchanged and it is a factor that perpetuates disparity. The funding of primary care is still largely based on capitation payments together with the more recent addition of target-based pay-for-performance rewards. Equality of practice funding in areas of high and low social deprivation, so-called ‘flat funding’, simply widens healthcare inequality in the presence of unequal healthcare needs.2 Marmot has advocated the principle of ‘proportionate universalism’, whereby universal healthcare provision is supplemented by targeted approaches related to the level of social need.3 But surely current primary care funding already invests in deprived communities? Capitation funding, accounting for the majority of funding, is not linked with social deprivation, although it is linked to measures of community ill health.4 The Carr-Hill …

Military veterans are likely to have encountered death, pain, and suffering, and to have prepared for them like few other groups in society. This is also a group trained to follow highly ceremonial rituals around death, burials, and commemoration. Yet veterans are not seen as ‘different’ in palliative and end-of-life care (EoLC), including that provided by GP practices. Throughout military service, encounters with death and dying are frequently intense, highly personal, and potentially traumatic, in ways seldom seen or understood in civilian life. Furthermore, the nature of military occupation — resembling more a lifestyle than a job — entails cultural separation from civilian life, with perceptions, norms, and ideals around death and dying forming part of this culture. Embodied experiences in military life as well as psychological, social, and ethical constructs (for example, guiding beliefs, value systems, norms, rules, and expectations) are often markedly different from those of civilian society. We do not know enough about how this legacy impacts the dying process in veterans and what the health services implications are, including in the context of general practice. There is a growing number of resources aiming to support GP practices in looking after their military veteran patients. Examples include the Royal College of General Practitioners’ (RCGP) ‘veteran-friendly GP practices’ initiative,1 the Veterans’ Healthcare Toolkit, the Military Veterans e-learning course, and the Veterans Health Days of Health Education England. The provision of EoLC, in turn, apart from being a traditional role for GPs, has had its profile raised significantly via the Quality Improvement domain introduced in the 2019 GP contract. In Year 1 of the contract (2019/2020), practices could achieve 37 points by engaging in continuous quality improvement of their EoLC services.2 Yet the intersection between the two types of population — veterans at the end of life …

BackgroundGeneral practice websites are an increasingly important point of interaction, but their readability is largely unexplored. One in four adults struggle with basic literacy, and there is a socioeconomic gradient. Readable content is a prerequisite to promoting health literacy.AimTo assess general practice website readability by analysing text and design factors, and to assess whether practices adapted their website text to the likely literacy levels of their populations.Design and settingWebsites for all general practices across Scotland were analysed from March to December 2019, using a cross-sectional design.MethodText was extracted from five webpages per website and eight text readability factors were measured, including the Flesch Reading Ease and the Flesch-Kincaid Grade Level. The relationship between readability and a practice population’s level of deprivation, measured using the Scottish Index of Multiple Deprivation (SIMD), was assessed. Overall, 10 design factors contributing to readability and accessibility were scored.ResultsIn total, 86.4% (n = 813/941) of Scottish practices had a website; 22.9% (n = 874/3823) of webpages were written at, or below, the government-recommended reading level for online content (9–14 years old), and the content of the remaining websites, 77.1% (n = 2949/3823), was suitable for a higher reading age. Of all webpages, 80.5% (n = 3077/3823) were above the recommended level for easy-to-understand ‘plain English’. There was no statistically significant association between webpage reading age and SIMD. Only 6.7% (n = 51/764) of websites achieved all design and accessibility recommendations.ConclusionChanges to practice websites could improve readability and promote health literacy, but practices will need financial resources and ongoing technical support if this is to be achieved and maintained. Failure to provide readable and accessible websites may widen health inequalities; the topic will become increasingly important as online service use accelerates.