In this episode, we talk to Professor Kate Brain, who is a Professor of Health Psychology, within the School of Medicine at Cardiff University.Title of paper: Satisfaction with remote consultations in primary care during COVID-19: a population survey of UK adultsAvailable at: https://doi.org/10.3399/BJGP.2023.0092Remote consultations became more widespread during the COVID-19 pandemic and continue to date. However, patterns of association between demographic characteristics and satisfaction with GP remote consultations during the pandemic were unclear. People with higher levels of educational qualification were found to have greater levels of satisfaction with remote GP consultations. Those with lower educational levels may benefit from further support with remote consultations.

In this episode, we talk to Dr Jennifer Voorhees, who is a GP in Tameside and an NIHR Academic Clinical Lecturer based at the University of Manchester. Title of paper: A paradox of access problems in general practice: a qualitative participatory case studyAvailable at: https://doi.org/10.3399/BJGP.2023.0276Access to general practice is an important topic, yet research and policies addressing access often take a simplistic definition, resulting in a lack of understanding of the complexities of longstanding interrelated problems. This research explains a paradox of access problems, in which the focus and attention on the increasing demand on general practice both creates and obscures another problem of unmet need. This is done through reactive rules and policies to manage demand, which largely undermine continuity in favour of speed of access, and generate work that takes up capacity of staff and patients. Clinicians can look at their current ways of working and identify ways to reverse the paradox in order to address hidden unmet needs and the resulting health inequalities in the population.

In this episode, we talk to Isabel Leach, who is a final year medical student at the University of Sheffield. Title of paper: Understanding patient views and experiences of the IDENTIfication of PALLiative care needs (IDENTI-Pall): a qualitative interview studyAvailable at: https://doi.org/10.3399/BJGP.2023.0071Understanding into patient views and experiences of identification of palliative care needs is lacking. This study suggests an individualised and compassionate approach is required, with key components including open conversations about palliative care and the sharing of prognostic uncertainty. Proactive palliative care intervention by primary healthcare professionals following identification of need is valued by patients and requires further attention in research, policy, and practice.

In this episode, we talk to Dr Alice Harper, an NIHR Academic Clinical Fellow based at the Centre for Academic Primary Care at the University of Bristol. Title of paper: Understanding the patient experience of coeliac disease diagnosis: a qualitative interview studyAvailable at: https://doi.org/10.3399/BJGP.2023.0299Previous qualitative studies on coeliac disease (CD) focus on patient experience after diagnosis. This study found patients experience uncertainty during the pathway to CD diagnosis, particularly pre-diagnosis and during investigations. Endoscopy was thought to be necessary for diagnostic confidence and conviction in a lifelong gluten free diet. As the diagnostic pathway evolves, consideration must be given to reducing patient uncertainty.

In this Christmas edition of the BJGP podcast we discuss Christmas stocking filler books. We're joined by Ben Hoban, Nada Khan, Euan Lawson and Andrew Papanikitas and talk through four books for the holiday season.

A quick note to say we're taking a break over Christmas but we'll be back with another BJGP Interview on 9 January 2024.

In this episode, we talk to Dr Garth Funston, who is a Clinical Senior Lecturer in Primary Care Cancer Research within the Wolfson Institute of Population Health at Queen Mary University of London.Title of paper: Pre-diagnostic prescription patterns in bladder and renal cancer: a longitudinal linked data studyAvailable at: https://doi.org/10.3399/BJGP.2023.0122Previous studies have demonstrated that prescription rates for certain medications increase many months before the diagnosis of some cancers. Determining whether prescribing for common urological clinical features increases in patients with renal and bladder cancer could help us identify opportunities for more timely diagnosis. We found that prescription rates for UTI medications increased 9 months before bladder and renal cancer diagnosis, with an even earlier increase occurring before bladder cancer diagnosis in women (11 months). This indicates that there is a window of opportunity in which investigation and referral could lead to earlier cancer detection in some patients presenting to their GP with features of UTI.

In this episode, we talk to Professor Stephane Jouneau, Professor in Pulmonology and Dr Anthony Chapron, a GP and Associate Professor from the University of Rennes in France. Title of paper: Early detection of chronic obstructive pulmonary disease in primary care: a randomised controlled trialAvailable at: https://doi.org/10.3399/BJGP.2022.0565 In primary care, the use of questions adapted from symptoms and risk factors identified by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and chronic obstructive pulmonary disease (COPD) coordination to facilitate spirometry access, either alone orcombined, facilitates COPD detection. These interventions are relatively easy to implement in everyday clinical practice and can be adapted for countries in which most GPs are not trained to perform spirometry.

In this episode, we talk to Professor Katharine Wallis, Head of the General Practice Clinical Unit at the University of Queensland in Brisbane, Australia. We caught up with her whilst she was in the UK to discuss the paper that she and first author Suzanne McDonald have published here in the BJGP. Title of paper: Acceptability and optimisation of resources to support antidepressant cessation: A qualitative think-aloud study with patientsAvailable at: https://doi.org/10.3399/BJGP.2023.0269It is not known how best to support patients to safely stop long-term (>12 months) antidepressants when there is no clinical indication for continued use. The current study tested and optimised three patient resources designed to raise awareness and recognition of withdrawal symptoms and to provide step-by-step guidance for tapering drug dose to minimise withdrawal symptoms. Adults with lived experience of long-term antidepressant use reported that the resources were useful, acceptable, clear, comprehensible, and reassuring. The effectiveness of these consumer-informed resources in supporting safe cessation of long-term antidepressants is currently being tested in general practice.

In this episode, we talk to Dr Georgia Richards, who is a Research Fellow in the Centre for Evidence-Based Medicine at the University of Oxford. Paper: Private prescribing of controlled opioids in England, 2014-2021: a retrospective observational studyAvailable at: https://doi.org/10.3399/BJGP.2023.0146There are concerns over the long-term, high-dose use of opioids in people with chronic pain – trends for which have been described using NHS prescription data. However, opioids can also be acquired from outside of NHS services, including private prescribers, over-the-counter (e.g. CoCodamol), and through online healthcare services and pharmacies or the “dark web”. Without exploring non-NHS data, the full picture of opioid use in England cannot be understood. This is one of the first studies that sought to fill this important gap by investigating opioid prescribing in the private sector. We found that the number of controlled opioid items prescribed by private prescribers in England halved between January 2014 and November 2021, and that most prescribing occurred from prescribers in London. There were also controlled opioid items dispensed by “unidentified doctors”, which must be addressed to ensure patient safety. While there is the monitoring of controlled drug prescribing by NHS England Controlled Drug Accountable Officers, expanding access to such data to allow for a greater visibility and wider analysis of non-NHS data, including the private prescribing of controlled opioids, will help identify harms and policy gaps that can be addressed to improve patient safety.

In this episode, we talk to Dr Monica Molinaro, who is an Assistant Professor at the Institute of Health Sciences Education at McGill University in Canada. Title of paper: You’re doing everything you possibly could do, and you know it’s not enough”: Family physician narratives of moral distressAvailable: https://doi.org/10.3399/BJGP.2023.0193The moral distress of physicians who cannot provide adequate care due to systemic deficits is seldom heard in contemporary discussions about health care access and quality. Family physician stories of moral distress in relation to structural and systemic factors such as racism, colonialism, and drug, mental health, and housing policy, generate seemingly novel and vital understandings of the clinical work of primary care providers. The study findings are some of the first to illustrate family physicians’ experiences of moral distress, contributing to the limited body of literature on moral distress in primary care.

In this episode, we talk to Dr Sharon James, a Research Fellow and Project Manager based at the School of Public Health and Preventive Medicine at Monash University in Australia. Title of paper: lnterconception care in Australian general practice: a qualitative studyAvailable at: https://doi.org/10.3399/BJGP.2022.0624Interconception care (ICC) provides an opportunity to address risk factors contributing to poor pregnancy outcomes. However, GP perceptions on providing ICC are not well established. ICC is not a familiar concept for GPs, it is delivered opportunistically and there is lack of clarity as to what ICC should consist of. GPs also feel there is lack of engagement and perceived value by women.

In this episode, we talk to Mr James Bailey, a Colorectal Research Fellow from the Nottingham Colorectal Service. Paper: Sociodemographic Variations in the Uptake of Faecal Immunochemical Tests in Primary CareAvailable at: https://doi.org/10.3399/BJGP.2023.0033FIT is increasingly used to triage patients with symptoms suggestive of colorectal cancer but variations in use by demographics, ethnicity and socioeconomic status are unknown. We show, in a large regional dataset, that male patients, patients under 65 years, the most deprived patients and ethnic minority groups are less likely to return a FIT sample. It is important that strategies are developed to ensure patients with these protected characteristics are not disadvantaged with the increasing usage of FIT to prioritise urgency of investigations.

In this episode, we’re doing something a bit different. Last week, the BJGP team attended the annual Royal College of GPs conference up in Glasgow, and presented a workshop looking at continuity of care. In this podcast, we’re going to pull together some of what we spoke about at that workshop, which highlighted some of the exceptional research that has been published in the BJGP on continuity, and also present a piece by Sir Denis Pereria Gray who also contributed to the workshop and spoke about how to put continuity into practice. Links to the research papers mentioned in this podcast:Relational continuity and patients’ perception of GP trust and respect: a qualitative studyhttps://doi.org/10.3399/bjgp20X712349Modernising continuity: a new conceptual frameworkhttps://doi.org/10.3399/bjgp23X732897Is continuity of primary care declining in England? Practice-level longitudinal study from 2012 to 2017https://doi.org/10.3399/BJGP.2020.0935Continuity of GP care for patients with dementia: impact on prescribing and the health of patientshttps://doi.org/10.3399/BJGP.2021.0413Team-based continuity of care for patients with hypertension: a retrospective primary care cohort study in Hong Konghttps://doi.org/10.3399/BJGP.2023.0150

In this episode, we talk to Dr Nish Jayasooriya, Research Fellow and specialist registrar in gastroenterology and hepatology. Paper: Adherence to 5-aminosalicylic acid maintenance treatment in young people with ulcerative colitis: a retrospective cohort study in primary careAvailable at: https://doi.org/10.3399/BJGP.2023.0006Adolescents and young adults diagnosed with ulcerative colitis (UC) are recommended long- term maintenance treatment for disease control, but adherence rates in primary care are unknown. This observational cohort study using real-world data from primary care found one-quarter of newly diagnosed adolescents and young adults, aged 10–24 years, discontinued oral 5-aminosalicylic acid (5-ASA) maintenance treatment within 1 month of starting and two-thirds within 1year. Young adults aged 18–24years and those living in a deprived area were most likely to discontinue and have poor adherence to treatment. Having an acute flare-up of UC was linked to better adherence to oral 5-ASA maintenance treatment. The first year of starting lifelong therapies among individuals diagnosed with UC is a critical window to improve adherence for adolescents transitioning to young adulthood and those from deprived postcodes.

In this episode, we talk to Dr Lizzie Emsley and Dr Eszter Szilassy from the University of Bristol. Paper: General practice as a place to receive help for domestic abuse during the COVID-19 pandemic: a qualitative interview study in England and WalesAvailable at: https://doi.org/10.3399/BJGP.2022.0528General practice is an important place for patients experiencing or perpetrating domestic violence and abuse (DVA) and for their children to seek and receive help. While the incidence of DVA may have increased during the COVID-19 pandemic, there has been a substantial reduction in DVA identifications and referrals to specialist services from general practice. At the same time, there has been the imposition of stringent lockdown measures and a rapid shift to remote care in general practice. This study explored patient experiences of seeking help for DVA in general practice during the COVID-19 pandemic, with additional insight from healthcare professionals. This study also included a focus on children affected by DVA. The authors found that patients affected by DVA had a strong preference for face-to-face consultation models in general practice for the opportunity of non- verbal communication. Children affected by DVA are a vulnerable group and this study reported concerns regarding their visibility to healthcare professionals in general practice during the pandemic.

In this episode, we talk to Dr Francine Toye and Dr Sharon Dixon, both working at Oxford on this project. Title of paper: Understanding primary care perspectives on supporting women’s health needs: a qualitative studyAvailable at: https://doi.org/10.3399/BJGP.2023.0141The Women’s Health Strategy for England highlighted a need to understand and develop how general practice can support women’s health needs. This study’s aim was to hear the voices of primary care practitioners with experience of delivering services, and to further understand what works well to provide quality care. Relationships and advocacy are at the core of general practice and women’s health, and this study highlights threats to these core values and skills. Care is needed when evolving services to ensure that relationship-based longitudinal knowledge of individuals, families, and communities is not devalued, as this is integral to high- quality health and social care.Here's the link to the previous podcast I mention here by the same team:https://bjgplife.com/episode-117-how-can-we-improve-our-care-for-ethnic-minority-women-through-the-menopause/

In this episode, we talk to Dr Jessica Watson, who is a GP and NIHR Academic Clinical Lecturer in general practice based at the Centre for Academic Primary Care at the University of Bristol.Paper: ‘Why test study: a UK-wide audit using the Primary Care Academic CollaboraTive to explore the reasons for primary care testing’.Available at: https://doi.org/10.3399/BJGP.2023.0191Previous research has shown a more than three-fold increase in the use of laboratory tests in UK primary care between 2000-2015, with significant variation in testing rates between GP practices. In this study around a quarter of tests were thought to be partially or fully unnecessary when reviewed retrospectively by another clinician. Around half of tests (48.8%) did not lead to any change in management or reassurance; 13.4% led to further blood tests or repeat blood tests, 2.7% led to further radiology tests. 6.2% of tests in primary care led to a new diagnosis or confirmation of diagnosis. This has important implications for how primary care clinicians talk to patients about blood tests, to ensure that patients have a better understanding and realistic expectations of the role of blood tests in their care.

In this episode, we talk to Dr Liz Sturgiss, who is an Associate Professor of Primary Care Research at the School of Primary and Allied Health Care at Monash University in Melbourne, Australia.Paper: Multifaceted intervention to increase the delivery of alcohol brief interventions in primary care: a mixed-methods process analysisAvailable at: https://doi.org/10.3399/BJGP.2022.0613Brief interventions can reduce alcohol- related harm when delivered in general practice, but there is an implementation gap in routine clinical practice. The REACH programme, which includes resources for patients, clinicians, and clinics, can improve alcohol recording in the general practice setting. Enhanced alignment between national policy and clinical need can support preventive health innovations through existing channels. When appropriately resourced and supported, general practice can deliver alcohol brief interventions in daily practice.

In this episode, we talk to Dr Victoria Welsh and Dr Claire Burton, who are both GPs and lecturers in primary care at the Centre for Musculoskeletal Health Research at Keele University. Title of paper: Trends in musculoskeletal consultations and prescribing: an electronic primary care records studyAvailable at: https://doi.org/10.3399/BJGP.2022.0648Rheumatic and musculoskeletal disorders (RMDs) are a common cause of pain and disability, with core non-pharmacological management supported by analgesic medications. To the author’s knowledge, no previous studies have observed the impact of the COVID-19 pandemic on the care of patients with rheumatic and musculoskeletal disorders (RMDs) in primary care, including consultation patterns and analgesic prescribing. This study demonstrates that fewer patients consulted with RMDs during lockdown, and a greater proportion were prescribed strong analgesia (including opioids) during pandemic-related restrictions. Clinicians appeared to respond to patient needs during the pandemic amidst restrictions placed upon non-pharmacological treatments, and commissioners must consider the impact of these behaviour changes during future pandemic planning.

In this episode, we talk to Margje van de Wiel from the Department of Work and Social Psychology, at Maastricht University in The Netherlands.Title of paper: ‘How do patients in general practice voice their gut feelings and value them?’Available at: https://doi.org/10.3399/BJGP.2022.0427We know that primary care professionals acknowledge the usefulness of patients’ gut feelings for their clinical reasoning. However, we do not precisely know the wordings and expressions patients use to voice their gut feelings and how they share them with professionals. The results we found may improve the professionals’ recognition of patients’ gut feelings and their insight into their background and enable further research into their validity.

We're taking a two week summer break, but why not hear more about the BJGP Research Conference which is being held on 22 March 2024. Learn more about the conference at https://bjgp.org/conference.

We're taking a two week summer break, but why not hear more about the BJGP Research Conference which is being held on 22 March 2024. Learn more about the conference at www.https://bjgp.org/conference.

In this episode, we talk to Line Pedersen and Anne Sophie Oxholm from the Research Unit for General Practice at the University of Southern Denmark.Title of paper: Mapping general practitioners’ motivation: It is not all about the money. A nation-wide cross-sectional survey study from DenmarkAvailable at: https://doi.org/10.3399/BJGP.2022.0563Understanding physicians’ motivation may be essential for designing policies and organisational structures that ensure the wellbeing and retention of GPs, and high-quality care. However, physicians’ motivation remains an understudied area. We find heterogeneity in GPs’ work motivation and identify five GP segments. The largest segment (53.2%) is characterised by being motivated ‘less by the money’.

In this episode, we talk to Charlie Coombs who is a medical student and School for Primary Care Research intern working at University College London. Title of paper: Opportunities, challenges and implications of primary care micro-teams for patients and healthcare professionals: an international systematic reviewAvailable at: https://doi.org/10.3399/BJGP.2022.0545The number of GP practices in the UK has overall reduced, whilst individual practice size lists have increased. This systematic review uses a framework analysis to synthesis the current literature available around micro-teams as a potential intervention to mitigate compromised care in larger practices. This review highlights micro-teams as a structure of general practice to promote accessible healthcare delivery and moderate losses to continuity. Further research in whether continuity can be offered by a team instead of an individual is warranted in the implementation of micro-teams.

In this episode, we talk to Professor Jonathan Mant who is Professor of Primary Care and Head of the Primary Care Unit within the Department of Public Health & Primary Care in the University of Cambridge. Title of paper: Progression of stroke risk in atrial fibrillation: Cohort study in general practiceAvailable at: https://doi.org/10.3399/BJGP.2022.0568New technologies are likely to result in younger people being diagnosed with atrial fibrillation who do not require anticoagulation treatment at diagnosis. There are few data to inform follow up of such people. Risk of development of hypertension and heart failure was found to be high in this group (indications for anticoagulation), suggesting

In this episode, we talk to Emma Whitfield, who is a PhD student in the Institute of Epidemiology and Health Care at University College London.Title of paper: Diagnostic windows in non-neoplastic diseases: a systematic reviewAvailable at: https://doi.org/10.3399/BJGP.2023.0044Improving timeliness of diagnosis is imperative across disease types. This review identified that for a range of nonneoplastic conditions healthcare use starts to increase in the time before diagnosis. For some conditions, this increase may first start to occur many years before diagnosis. Further research is needed to produce accurate estimates of how much earlier diagnosis may be possible.

In this episode, we’re going to do something a bit different and recognise some exceptional researchers here in the UK. We talk to Dr Sarah Bailey and Dr Ben Brown, this year’s winners of the Royal College of GPs and Society for Academic Primary Care early career researcher award. This award, which has a long history of recognising the up and coming superstars of primary care research, recognises the contribution of early career researchers to advancing primary care theory and practice.

In this episode, we talk to Dr Laura Jefferson, who is a Research Fellow within the Department of Health Sciences at the University of York. Title of paper: ‘Exploring gender differences in uptake of GP partnership roles: a qualitative mixed methods study’. Available at: https://doi.org/10.3399/BJGP.2022.0544An unadjusted gender pay gap of 33.5% exists in general practice, reflecting partly the differential uptake of partnerships amongst women GPs, but evidence exploring gender differences in GPs’ career progression is sparse. Our mixed methods approach used interview data, social media analysis and asynchronous online focus groups to explore factors affecting uptake of partnership roles, focusing particularly on gender differences. Factors at individual, organisational and national levels influence partnership uptake and career decisions of both men and women GPs, though gender differences were apparent with women reporting greater challenges balancing work/family, negative working conditions including maternity and sickness pay and discriminatory practices perceived to favour men and full time GPs. The relative attractiveness of salaried, locum or private roles in general practice appears to discourage both men and women from partnerships presently. Promoting positive workplace cultures through strong role models, improved flexibility in roles and skills training could potentially encourage greater uptake amongst both men and women.

In this episode, we talk to Ruth Swann who is a Senior Analyst for Cancer Research UK in partnership with NHS England, about the study she’s published alongside colleagues here in the BJGP. Title of paper: Comparison between the 2018 and 2014 National Cancer Diagnosis Audits for EnglandAvailable at: https://doi.org/10.3399/BJGP.2022.0268There is ongoing national monitoring of elements of the cancer referral process from primary care, including the proportion of urgent referrals (‘2-week waits’, TWW) and emergency presentations. The 2014 National Cancer Diagnosis Audit (NCDA) provided a richer picture of this process, as reported by GPs themselves. This research presents a direct comparison of that audit to the more recent one carried out on patients diagnosed in 2018, with revised NICE guidance on referral of suspected cancer having been published in 2015, showing the changes in practice and their direction.

In this episode, we talk to Dr Alex Hodkinson, who is an NIHR senior research fellow within the NIHR Patient Safety Translational Research Centre at the University of Manchester. Title of paper: Association of strong opioids and antibiotics prescribing with GP burnout: a retrospective cross-sectional study’. Available at: https://doi.org/10.3399/BJGP.2022.0394Prescribing has important implications for patient safety; this is particularly the case for high-risk medications such as strong opioids, and medications where there may be public health implications such as antibiotics. Physician wellness such as burnout can also have a significant impact on the productivity of healthcare organisations, intentions to leave medical practice, and both the quality and safety of patient care. At present, it is unclear if there is an association between the wellness of GPs within general practices and overprescribing of strong opioids and antibiotics in primary care in England. Over a 4-month period this study found higher prescribing of strong opioids and antibiotics among GPs with burnout symptoms, job dissatisfaction, and turnover intentions; working longer hours; and in practices based in the north of England serving more deprived populations.

In this episode, we talk to Ameerah Ibrahim and Carmel Hughes about the paper they’ve recently published in the BJGP titled, ‘GPs’ and pharmacists’ views of integrating pharmacists into general practices: a qualitative study’Title of paper: GPs’ and pharmacists’ views of integrating pharmacists into general practices: a qualitative studyAvailable at: https://doi.org/10.3399/BJGP.2022.0518Little is known about primary healthcare professionals’ views on the impact of practice-based pharmacists (PBPs) in general practice. Participants interviewed in this study reported that PBPs had integrated well and perceived a positive impact on primary healthcare delivery. The findings indicated that continued integration would need PBPs, all members of the practice team, and community pharmacists (CPs) to understand each other's roles well and to communicate clearly to ensure the delivery of efficient PBP-led patient care. A number of areas for development were identified such as patient awareness of the role and communication pathways between PBPs and CPs.

Today we are talking to Dr Nick Thomas, who is clinical lead for research at the Royal College of General Practice here in the UK.Read more about research here at the RCGP: https://www.rcgp.org.uk/representing-you/research-at-rcgpAnd for more information about the Research and Surveillance Centre, look here: https://www.rcgp.org.uk/representing-you/research-at-rcgp/research-surveillance-centreIf you are looking for research funding opportunities through the RCGP, read more here: https://www.rcgp.org.uk/representing-you/research-at-rcgp/how-rcgp-support-your-research#grants

In this episode, we talk to Dr Joe Hutchinson, an academic clinical fellow at the Centre for Primary Care and Health Services Research at the University of Manchester. Title of paper: Consequences of the closure of General Practices: a retrospective cross-sectional studyDOI: https://doi.org/10.3399/BJGP.2022.0501Closures of UK general practices are increasingly common, yet little is known about the consequences. This cross-sectional study of English general practices finds practice closures increase list size in exposed practices, with changes in workforce composition and reductions in patient satisfaction.

In this episode, we talk to Dr Faraz Mughal, who is a practising NHS General Practitioner and NIHR Doctoral Fellow at the School of Medicine at Keele University. Title of paper: Recent GP consultation before death by suicide in middle-aged males: a national consecutive case series studyAvailable at: https://doi.org/10.3399/BJGP.2022.0589Preventing suicide in middle-aged males is a global priority. This national case series study found that 43% of middle-aged males who died by suicide had a final GP consultation in the preceding 3 months, and of these males, over half presented with a mental health problem. Males who had recent GP contact before suicide were more likely to have self-harmed in the 3 months before compared with males who had no recent GP contact. Males who had a current physical illness, recent history of self-harm, attended for a mental health problem, and experienced recent work-related problems were more likely to consult with their GP shortly before dying by suicide. GPs and primary care clinicians should be alert to these clinical factors that may be proximal to suicide, and in turn, offer personalised holistic care.

In this episode, we talk to Dr James Sheppard, who is an Associate Professor at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. Title of paper: Predicting the risk of acute kidney injury: Derivation and validation of STRATIFY-AKIAvailable at: https://doi.org/10.3399/BJGP.2022.0389Acute kidney injury (AKI) is one of the more serious adverse events associated with antihypertensive treatment, reducing an individual’s health-related quality of life and increasing the risk of admission to hospital. Clinical guidelines recommend that when prescribing antihypertensives GPs should take into account the likelihood of both the benefits and harms from treatment, but few data exist in regard to the risk of AKI. A clinical prediction model was developed and externally validated for the risk of AKI up to 10 years in the future in patients eligible for antihypertensive medication, incorporating commonly recorded patient characteristics, comorbidities, and prescribed medications. The model showed good discrimination and good calibration for probabilities up to 20%, enabling GPs to accurately identify patients at higher risk of AKI. This could be useful to reassure the majority of patients starting or continuing treatment that their risk of AKI is very low.

In this episode, we talk to Gillian Doe and Rachael Evans, both based at the University of Leicester. Title of paper: Diagnostic delays for breathlessness in primary care: a qualitative study to investigate current care and inform future pathwaysAvailable at: https://doi.org/10.3399/BJGP.2022.0475Delays to diagnosis for patients presenting with chronic breathlessness are well described. This study set out to investigate current care for patients awaiting a diagnosis to inform future diagnostic pathways. The data highlight the challenges of symptom recognition, timely investigations, making a positive diagnosis, and difficult consultations. To achieve earlier diagnosis and better outcomes for patients with breathlessness, clinicians need to Ask, Act, and Advise: Ask to understand and validate symptoms, Act to initiate timely investigations, and Advise a positive diagnosis while offering breathlessness relief strategies.

In this episode, we talk to Jennifer MacLellan and Sultana Bi about the paper they have recently published here in the BJGP. Title of paper: Primary care practitioners’ experiences of peri/menopause help-seeking among ethnic minority womenAvailable at: https://doi.org/10.3399/BJGP.2022.0569Ethnic minority women may have different experiences of the peri/menopause from their white peers. Ethnic minority women may face language, inhibition and health literacy barriers to primary care. There is a need for increased awareness and trustworthy information resources to help ethnic minority women prepare for the menopause and advocate for their health. Resources, training and quality interpreter support are needed to help clinicians recognise ethnic minority women’s experiences and offer support, improving quality of life and potentially reducing future disease risk.

In this episode, we talk to Dr Gail Davidge and Dr Brian McMillan, who are both based at the Centre for Primary Care and Health Services Research at the University of Manchester.Title of paper: Putting principles into practice: A qualitative exploration of the views and experiences of primary care staff regarding patients having online access to their electronic health recordAvailable at: https://doi.org/10.3399/BJGP.2022.0436Previous research has noted primary care staff concerns about patients having online access to their health record, relating to issues such as: workload, safeguarding, patient confusion or distress, and health inequities. This study provides additional insights in the aftermath of the Covid-19 pandemic and in the light of NHS England’s plans to enable full prospective records access for patients by default. Findings highlight that most primary care staff agree with patient records access in principle, and can see its potential benefits, but remain concerned about the impact on patient centred care, safeguarding, and how to navigate this change. This study underlines the need for additional training and support for primary care staff to adapt their practice so they can address the needs of patients and protect patient safety and well-being whilst maintaining the clinical integrity of health records.

In this episode, we talk to Professor Jon Emery, who is the Herman Chair of Primary Care Cancer Research at the University of Melbourne. Title of paper: The CRISP Trial: RCT of a decision support tool for risk-stratified colorectal cancer screeningAvailable at: https://doi.org/10.3399/BJGP.2022.0480Using risk models that account for family history, lifestyle and medical history could tailor CRC screening and determine starting age and screening test. This could be more cost-effective than population screening. In this RCT, we showed that using the CRISP risk tool in general practice can increase risk-appropriate CRC screening in those due screening. Its effect is more uncertain in patients who are up-to-date with screening. The CRISP intervention could be used in people in their fifth decade to ensure people start CRC screening at the optimal age with the most cost-effective screening test.

In this episode, we talk to Dr Emma Ladds, who is a Primary Care In-Practice Fellow and GP based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford.Title of paper: ‘How have remote care approaches impacted continuity? A mixed-studies systematic review’Available at: https://doi.org/10.3399/BJGP.2022.0398The value of continuity in primary care has been repeatedly demonstrated for multiple outcomes. However little is known about how the expansion of remote and digital care models have impacted continuity. Here we demonstrate a disturbing lack of systematic research in this area and emphasize the need for real world explorations of the links between the shift to remote care, continuity and equity to ascertain when and for whom continuity adds most value and how this can be enabled or maintained.

In this episode, we talk to Maria Mathews, who is a Professor in the Department of Family Medicine at Western University in Canada. Title of paper: Strengthening the integration of primary care in pandemic response plans: A qualitative interview study of Canadian family physiciansAvailable at: https://doi.org/10.3399/BJGP.2022.0350Previous pandemic plans have largely overlooked the important role of primary care in a pandemic response. The COVID-19 pandemic presents a novel opportunity to examine the key roles family physicians play during a pandemic, and sheds light on existing barriers and supports. Findings from this study highlight the need for greater incorporation of primary care in the development of strengthened pandemic plans.

In this episode, we talk to Professor Lucy Ziegler, Professor of Palliative Care and head of the St Gemma’s Academic Unit of Palliative Care at the University of Leeds.Title of paper: What characterises good home-based end-of-life care: Analysis of 5-year data from a nationwide mortality follow-back survey in EnglandAvailable at: https://doi.org/10.3399/BJGP.2022.0315Determinants of high quality care for patients living at home during their last three months of life are not well understood. We analysed 5-year data from a large, nationally representative bereavement survey collecting information on experiences and quality of end-of-life care for adults with advanced disease, in England. The importance of good continuity of care from general practitioners on positive outcomes is identified as a potentially modifiable factor. Inequity in access to good end-of-life care is highlighted, with patients from lower socio-economic and minority ethnic groups less likely to receive good end-of-life care.

In this episode, we talk to Dr Simon Beerten, who is a GP and a research fellow from the Department of Public Health and Primary Care at KU Leuven in Belgium. Title of paper: Trends in the registration of anxiety in Belgian primary care from 2000 to 2021: A registry-based studyAvailable at: https://doi.org/10.3399/BJGP.2022.0196Figures on anxiety in general practice are scarce. This study shows increasing incidence and prevalence of physician-registered anxiety. Patients with anxiety had an increasing number of comorbidities over time. Treatment of anxiety in this setting seems very dependent on medication, particularly SSRIs and anxiolytics.

In this episode, we talk to Professor Niro Siriwardena, Professor of Primary and Pre-hospital Health care at the School of Health and Social Care at the University of Lincoln. Title of paper: Academic performance of ethnic minority versus White doctors in the MRCGP assessment 2016-2021: cross sectional studyAvailable at: https://doi.org/10.3399/BJGP.2022.0474Differential attainment is widely found in undergraduate and postgraduate medical examinations. It has been suggested that subjective bias due to racial in discrimination clinical skills assessments may be a cause of examination failure for UK trained ethnic minority candidates and international medical graduates. No previous study has examined differential attainment in all components of GP licensing assessments including workplace-based assessment, taking into account scores at selection in GP specialty training. Ethnicity did not reduce the chance of passing GP licensing tests once Sex, place of primary medical qualification, declared disability and selection (multispecialty recruitment assessment) scores were taken into account. Doctors admitted to GP speciality training who are in the lowest MSRA score bands may need additional support during training to maximise their chances of achieving licensing regardless of their ethnicity or other demographic characteristics.

In this episode, we talk to Professor Joe Kai, who is a GP and Clinical Professor in the Centre for Academic Primary Care at the University of Nottingham. Title of paper: Women’s experiences of heavy menstrual bleeding and medical treatment: Qualitative studyPaper available at: https://doi.org/10.3399/BJGP.2022.0460Heavy menstrual bleeding (HMB) is known to significantly affect women’s health and quality of life, with pressure to conceal symptoms. Recent evidence on women’s experiences of HMB and its treatment after seeking primary care is lacking. This research shows the debilitating impacts of HMB on women, and the challenges they can still face, including overcoming taboo and low general awareness that treatment can help. Women had widely differing experiences of current medical treatments for HMB in general practice, and emphasised how they valued patient-centred communication and involvement in decisions in helping them.

In this episode, we talk to Kelly Lloyd, who is a research fellow within the Leeds Institute of Health Sciences at the University of Leeds.Title of paper: A factorial randomised trial investigating factors influencing general practitioners’ willingness to prescribe aspirin for cancer preventive therapy in Lynch syndrome: a registered reportAvailable at: https://doi.org/10.3399/BJGP.2021.0610National Institute for Health and Care Excellence (NICE) guidance for England and Wales recommends daily aspirin for colorectal cancer prevention in people with Lynch syndrome, and it is likely that prescribing will occur in primary care. GPs may be reluctant to prescribe due to concerns about the side-effects, supporting evidence and lack of awareness of the NICE guidance. In a randomised factorial trial, providing GPs with information on these factors did not increase willingness to prescribe, or comfort discussing harms and benefits. Alternative strategies targeting multiple levels of prescribing behaviour among unwilling GPs may support prescribing.

In this episode, we talk to Dr Sarah Tonkin-Crine, an Associate Professor and Health Psychologist based within the Nuffield Department of Primary Care Health Sciences at the University of Oxford. Title of paper: Implementing antibiotic stewardship in high prescribing English general practices: a mixed-methods studyAvailable at: https://doi.org/10.3399/BJGP.2022.0298An intervention to support the implementation of three evidence-based antimicrobial stewardship (AMS) strategies was evaluated in nine high antibiotic prescribing general practices in England. General practice teams received intervention materials and chose to use them in substantially different ways in real-life settings, outside of trial conditions. AMS strategies are complex interventions that require sufficient understanding and engagement by clinicians for successful adoption and use, to obtain the full benefit in reducing antibiotic prescribing. This study highlights that remote, one-sided delivery of AMS strategies should be done cautiously to avoid misunderstanding and sub-optimal use.

In this episode, we talk to Dr Bianca Perera, a GP in Tasmania who is undertaking a PhD at Monash University.Title of paper: General practice management of COPD patients following acute exacerbations: a qualitative studyAvailable at: https://doi.org/10.3399/BJGP.2022.0342The period immediately following an acute exacerbation of COPD is a high-risk period for recurrence and a critical time to intervene. Hospital-initiated, guideline-based care bundles have been previously proposed to optimise post-exacerbation care and reduce readmission, however convincing evidence of effectiveness has been lacking. As post-exacerbation care is mainly delivered by GPs in Australia, this study describes detailed insights from their perspectives regarding factors affecting the provision of evidence-based care in the period following hospital discharge. The findings highlight factors that should be addressed to enhance care of COPD patients to prevent future exacerbations and hospital readmissions.

In this episode, we talk to Dr Karin Smit, who is a GP trainee and PhD student at the Department of General Practice at Utrecht University in The Netherlands. Title of paper: Home monitoring by pulse oximetry of primary care patients with COVID-19 - a pilot randomised controlled trialAvailable at: https://doi.org/10.3399/BJGP.2022.0224During the course of the pandemic, home or remote monitoring of COVID-19 patients by pulse oximetry took off. However, studies on its use are scarce. Our pilot randomised controlled trial showed that home monitoring of moderate-severe COVID-19 patients with a validated pulse oximeter is feasible; adherence was high, patients reported a high feeling of safety, while the number of primary care consultations remained similar to usual care. We believe these pragmatic findings form an important building block for safe implementation of pulse oximetry as a home monitoring tool in primary care.

In this episode, we talk to Dr Sarah Sowden, an Advanced Academic Clinical Fellow and honorary consultant in Public Health at Newcastle University. Title of paper: Which non-pharmaceutical primary care interventions improve mental health amongst socioeconomically disadvantaged populations? Systematic reviewAvailable at: https://doi.org/10.3399/BJGP.2022.0343New models of healthcare and clinical practice, such as social prescribing and collaborative care, are increasingly used as non-pharmaceutical alternatives for treating common mental disorders (CMDs) in primary care. However, there is a lack of evidence available to GPs about the effectiveness of these types of interventions for socioeconomically disadvantaged patients, among whom CMDs are most prevalent. This systematic review synthesised the international evidence exploring the impact on CMD outcomes for socioeconomically disadvantaged patients. Although the evidence base was weak, there was evidence for an overall positive effect on anxiety, depression, self-reported mental health and wellbeing.

In this episode, we talk to Professor Emma Wallace, who is a GP and Professor of General Practice at University College Cork about the incidence and severity of adverse drug reactions in older adults in the community. Title of paper: Cumulative incidence and severity of adverse drug reactions and associated patient characteristics in older community-dwelling adults attending general practice – a six year prospective cohort studyAvailable at: https://doi.org/10.3399/BJGP.2022.0181No prospective studies have examined adverse drug reaction (ADR) occurrence among older adults attending general practice. ADRs were found to occur for approximately 1 in 4 older adults over a six-year period. Cardiovascular, nervous system and anti-infective drugs for systemic use were the most commonly implicated drug classes. Approximately 1 in 4 ADRs rated as moderate result in additional healthcare utilisation. Female sex, polypharmacy (5-9 drug classes) and major polypharmacy (≥10 drug classes) increased the likelihood for ADRs.

Today, we talk to Becky White, who is a Research Fellow at the Epidemiology of Cancer Healthcare and Outcomes Research Group at UCL. Paper: Underlying cancer risk among patients with fatigue and other vague symptoms in primary care: a population-based cohort studyAvailable at: https://doi.org/10.3399/BJGP.2022.0371When patients present to GPs with new-onset fatigue and no alarm symptoms for cancer, optimal management is often unclear, as it is not known which of these patients may be at risk of having present but currently undetected cancer. We found that among fatigue presenters without alarm symptoms, the chance of underlying cancer exceeded risk referral thresholds of 3% in older men with fatigue combined with any of another 19 vague symptoms for cancer, and in older women with fatigue-weight loss, fatigue-abdominal pain, or fatigue-abdominal bloating. These findings can support diagnostic management and referral decisions for patients presenting with fatigue in the absence of alarm symptoms for cancer.

Today, we talk to Dr Claire Taylor, a GP and NIHR Clinical Lecturer at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. Paper: Natriuretic peptide testing and heart failure diagnosis in primary care: diagnostic accuracy studyAvailable at : https://doi.org/10.3399/BJGP.2022.0278International guidelines recommend natriuretic peptide (NP) testing to prioritise referral for heart failure (HF) diagnostic assessment in primary care. European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) guidelines differ significantly in their recommended NP referral threshold. Our study found at the lower ESC threshold fewer HF diagnoses were missed but more referrals from primary care would be required. Healthcare systems need to balance the risk of a missed or delayed diagnosis for individual patients with capacity in diagnostic services. An NP level below both the ESC and NICE thresholds was reliable in ruling out HF.

This episode (our 100th podcast!), we have a round table discussion with our Editor-in-Chief, Euan Lawson, alongside the editorial team of Sam Merriel, Tom Round and Nada Khan. We take a look at the top 10 most read papers on the BJGP website from 2022

In this episode, we talk to Dr Kitty Worthing, a GP registrar working for the Sheffield Teaching Hospitals Trust about work she did whilst working as an academic clinical foundation doctor and then clinical fellow at Queen Mary University. Title of paper: Reluctance to register: an exploration of the experiences and perceptions of general practice staff in North East LondonAvailable at: https://doi.org/10.3399/BJGP.2022.0336Previous research shows that people are often refused GP registration if they do not have access to documentation, highlighting a discrepancy between guidance and practice that has not been previously explored. Current third sector initiatives to improve inclusive registration have largely focused on reiterating guidance and explaining to staff why people may not have access to documentation. This study found that reluctance to register this group was common, and reluctance was generally fuelled not by lack of knowledge of the guidance, but by workplace and resourcing pressures, and moral judgements concerning who should be entitled to NHS services based on immigration status. The perceived practical and financial burdens relate to overall increases in workload and the current funding model utilised in general practice. Initiatives to improve access must acknowledge such concerns, alongside addressing the wider malign impact of the ‘hostile environment’ policies on individual staff decision making.

Today, we talk to Professor Paul Little, who is Professor of Primary Care Research within Medicine at the University of Southampton. Paul and his team conducted a study looking at the effectiveness of antibiotics for chest infections in children. Title of paper: Antibiotic effectiveness for children with lower respiratory infections: prospective cohort and trialAvailable at: https://doi.org/10.3399/BJGP.2022.0239Antibiotics are commonly prescribed for children with chest infections, but prescribing antibiotics fuels antibiotic resistance which is one of the major global public health threats. There is little randomised evidence, and trials commonly recruit selected populations which undermines their applicability. In a cohort of unwell children antibiotics for chest infections were not effective in significantly shortening the illness, and increased side effects. GP’s should support parents to self-manage at home and communicate clearly on when and how to seek medical help if they continue to be concerned.

In this episode, we talk to Nishadi Withanage, a doctoral student in the Department of General Practice at Monash University in Australia. Title of paper: Effectiveness of preconception interventions in primary care: a systematic reviewAvailable at: https://doi.org/10.3399/BJGP.2022.0040Preconception care (PCC) delivered in community and hospital settings are effective in improving pregnancy outcomes and health knowledge, and reducing preconception risk factors; however, the effectiveness of primary care-based PCC has been unclear. This systematic review demonstrates that primary care-based PCC including brief and intensive education, supplementary medication, and dietary modification are effective in improving health knowledge and reducing preconception risk factors among females, even when delivered by trained non-healthcare professionals. Non-healthcare professionals could help improve access to PCC in systems that are already struggling to provide care. As there is a limited number of studies reporting on pregnancy outcomes, further research is required to determine whether primary care-based PCC can improve pregnancy outcomes.

Today, we talk to Mai Stafford, who is a senior analytical manager at the Health Foundation. Title of paper: Continuity of care in diverse ethnic groups: a general practice record study in EnglandAvailable at: https://doi.org/10.3399/BJGP.2022.0271Nationally representative survey data show lower continuity of care for most ethnic minority groups. To the authors’ knowledge, this is the first national study to examine ethnic inequalities in continuity of care using GP records. The study found that relational continuity of care was lower for people from Black African, Black Caribbean, any other Black background, Bangladeshi, and Pakistani ethnic groups. These ethnic inequalities are not accounted for by socioeconomic deprivation and are seen for people with and without multiple long-term conditions.

In this episode, we talk to Dr Laura Armitage, a GP and Doctoral Research Fellow at the Nuffield Department of Primary Health Care Sciences at the University of Oxford. Laura and her team conducted a study looking at a common issue in primary care: hypertension, and how to measure it in practice.Title of paper: Diagnosing hypertension in primary care: the importance of night-time blood pressure assessment. Available at: https://doi.org/10.3399/BJGP.2022.0160Since the 1990s, the phenotypic classification of 24-hour blood pressure has divided the population into ‘dippers’, ‘non-dippers’ (minimal night-time BP decrease compared to daytime BP) and ‘reverse dippers’ (night-time BP increases compared to day-time BP). There is an established body of research demonstrating that reverse dippers are at higher risk of death and that the night-day systolic blood pressure ratio is an independent predictor of all cause mortality and cardiovascular events. Presently, UK guidelines suggest clinicians should diagnose hypertension based solely on daytime BP measurements. This study reveals a marked proportion of our population are reverse dippers; together with the established clinical research that has demonstrated worse cardiovascular outcomes for such patients, this highlights the need for 24-hour ambulatory blood pressure assessments to detect and diagnose those with nocturnal hypertension, non-dipping or reverse-dipping blood pressure phenotypes. 

In this episode, we talk to Dr Pauline Williams, a GP and an NRS Career Research Fellow. She’s based at the Institute of Applied Health Sciences at the University of Aberdeen.Title of paper: Help seeking behaviour in women diagnosed with gynaecological cancer: a systematic review. Available at: https://doi.org/10.3399/BJGP.2022.0071Reducing diagnostic delay, by improving patients’ help seeking behaviour, may reduce the UK’s excess gynaecological cancer mortality. This review identifies that symptom knowledge is not enough to initiate help seeking; patients must also have the time or means to attend health care and be motivated enough, by previous experience, to overcome any fear or embarrassment they may have.

In this episode, we talk to Julien Vos, who is a doctoral student and clinician based at the Department of General Practice at the University of Amsterdam. We’re going to discuss his paper about survivorship care for colorectal cancer and patients experiences of GP-led care in the Netherlands.  Paper: Patients’ experiences with general practitioner-led colon cancer survivorship care; a mixed-methods evaluation at various time pointsAvailable at: https://doi.org/10.3399/BJGP.2022.0104Cancer survivorship care is often complex and requires a multi-dimensional approach. Patients receiving colon cancer survivorship care from either the GP or surgeon rate the received care as of high quality. Roles and responsibilities of patients and physicians need to be clear in order to help organize survivorship care. GPs can take on a more prominent role in cancer survivorship care, but other outcomes, including patients’ and physicians’ preferences, will also be important.

In this episode, we talk to Professor Jeremy Horwood, Professor of Social Science and Health at the Centre for Academic Primary Care at the University of Bristol. Paper: Unintended consequences of patient online access to health records: a qualitative study in UK primary careAvailable at: https://doi.org/10.3399/BJGP.2021.0720Previous studies of patient online access to their medical records have noted a range of concerns about potential unintended consequences. This study reports real-world experiences of the consequences of online access. We identified unintended consequences that impacted patient autonomy and GP documentation practices, and also increased workload through providing access while avoiding harm to patients. It is crucial that practices are adequately supported and resourced to manage the unintended consequences of online access now that it is the default position.

In this episode, we talk to Ben Cranfield, who is undertaking a PhD In the Department of Behavioural Science and Health at UCL. Paper: Primary care blood tests before cancer diagnosis: National Cancer Diagnosis audit dataAvailable at: https://doi.org/10.3399/BJGP.2022.0265Evidence relating to the predictive value of blood tests for cancer diagnosis is growing, yet how often they are used by GPs in pre-diagnosed cancer patients is unclear. In England, two-fifths of patients subsequently diagnosed with cancer in 2018 had at least one full blood count, urea & electrolyte or liver function test. Blood test use was less likely in women, non-white and younger patients and more likely in those presenting with non-specific symptoms, with longer intervals to referral and diagnosis being associated with tested patients. This research highlights potential unmet need for interventions to reduce the risk of overuse (in populations presenting with more-specific symptoms) and underuse (in patients presenting with less-specific symptoms) of blood tests in cancer populations.

In this episode, we talk to Maha Abo-Tabik, a doctoral research student at the Global Psoriasis Atlas who is based at the University of Manchester.Paper: Mapping opportunities for the earlier diagnosis of psoriasis in primary care settings in the UKAvailable at: https://doi.org/10.3399/BJGP.2022.0137Many people suffer needlessly from psoriasis due to missed or delayed diagnosis. Primary care professionals are most often the first point of contact for people with psoriasis. The diagnosis of psoriasis can be a challenging task for non-dermatologists. Examining electronic health records from general practices showed that the diagnosis of psoriasis may be missed or delayed. People with undiagnosed psoriasis (missed or delayed diagnosis) have an increased frequency of GP consultations from five years before their diagnosis of psoriasis is confirmed. Individuals with psoriasis are often prescribed topical corticosteroids and/or topical antifungal medications before being diagnosed with psoriasis. These medications may mask the signs of psoriasis.

In this episode, we talk to Professor Trish Greenhalgh, Professor of Primary Care Health Sciences at the University of Oxford. Paper: UK newspapers “on the warpath”: media analysis of remote consulting in 2021Available at: https://doi.org/10.3399/BJGP.2022.0258How this fits inIn 2020, the shift from in-person to remote consulting in general practice was depicted positively by the media as part of the “war” on COVID-19. In 2021, remote consulting was depicted negatively by the media, and linked in press articles to difficulties accessing primary care and compromises in patient safety.  Newspapers led campaigns which successfully put pressure on government to require a return to in-person consultations. 

In this episode, we talk to Dr Natasha Tyler and Dr Maria Panagioti who both work in the Centre for Primary Care and Health Services Research at the University of Manchester.Paper:  Patient Safety, Self-injection and B12 deficiency: A UK Cross sectional studyhttps://doi.org/10.3399/BJGP.2021.0711It is known that individuals with vitamin B12 deficiency (including pernicious anaemia) describe their primary care consultations as ‘battles’ and feel stigmatised. However, the extent of this dissatisfaction with primary care and the effect this might have on patient safety and unsafe health behaviours is unknown. This is the first study to assess the association between patient reported safety and self-medication via injection and to consider the contributory factors to patient safety that affect this patient group. Understanding any negative effects of current practice and how general practitioners and primary care clinicians can better meet the needs of this marginalised group is key, to improving safety and care.

In this episode, we talk to Dr Dan Jones, who is a GP and an Academic Clinical Lecturer at the University of Leeds.Paper: Factors influencing symptom appraisal and help-seeking of older adults with possible cancer: a mixed methods systematic reviewhttps://doi.org/10.3399/BJGP.2021.0655The burden of cancer falls predominantly on older (≥65 years) adults, and prompt presentation to primary care with cancer symptoms results in better patient outcomes. The current review, which included 80 studies, found that older adults with cancer symptoms may have prolonged symptom appraisal and shorter help-seeking intervals prior to presenting to general practice. Factors such as knowledge of cancer symptoms, the influence of family and carers, fear, embarrassment, comorbidities, and patient self-management all affected the appraisal or help-seeking interval. Clinicians should be aware of patient difficulty in distinguishing potentially worrying cancer symptoms from symptoms of ageing as a result of frailty or comorbidities.

In this episode we talk to Dr Lieke Koggel who is a PhD candidate in gastroenterology at the Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, The Netherlands.Paper: Predictors for inappropriate proton pump inhibitor use: observational study in primary carehttps://doi.org/10.3399/BJGP.2022.0178While overuse of proton pump inhibitors (PPI) is a common issue worldwide, predictors for this remain insufficiently known. This observational study using real-world primary care data identified older age and non-selective NSAID use as most predictive for inappropriate PPI use. The study also showed that unnecessarily continued PPI therapy is common in patients using PPI therapy for dyspepsia or as ulcer prophylaxis. Future initiatives on reducing inappropriate PPI use should target these patient groups.

In this episode we talk to Dr Simon Fraser who is a GP and associate professor of public health at the School of Primary Care, Population Sciences, and Medical Education at the University of Southampton.Paper: Change in treatment burden among people with multimorbidity: a follow-up surveyhttps://doi.org/10.3399/BJGP.2022.0103The extent to which treatment burden changes over time and which groups of people are likely to experience increases or decreases in treatment burden is not known. This study identified that a third of older adults with multimorbidity experienced an increase in treatment burden category (overall 9% moving to the ‘high’ treatment burden category), and that living more than 10 minutes away from their GP – particularly for those with limited health literacy - was associated with an increase in treatment burden. Improving patient access to primary care services and enhancing health literacy may help to mitigate increases in treatment burden. Our revised single-item measure performed moderately, suggesting a brief measure of treatment burden consisting of more than one item may be required for use in practice.

In this episode we talk to Dr Sally Hull who is a GP and Honorary Reader in Primary Care Development at QMUL.Paper: Measuring continuity of care in general practice: a comparison of two methods using routinely collected datahttps://doi.org/10.3399/BJGP.2022.0043Longitudinal continuity of care is associated with lower mortality, fewer hospital admissions, better care for chronic disease and greater patient satisfaction. In spite of these benefits few practices measure continuity and measurement is not supported by health policy. Using the UPC we report a strong correlation between patient measures of continuity and practice UPC scores. We illustrate GP continuity across a whole health economy, and demonstrate that patient age and practice size are the strongest predictors. Improving continuity will require incentivisation, and regular measurement to support change.

We have a quick update from the editor, Euan Lawson, as we take a short break over the summer. Here are some links to ensure you stay in touch with us:BJGP Life: https://www.bjgplife.com. (And details on contributing here: https://www.bjgplife.com/contribute)Twitter: @BJGPjournalFacebook: https://www.facebook.com/BJGPjournal/YouTube: https://www.youtube.com/c/BJGPjournalRCGP members opt in for your print journal here: https://bjgplife.com/print

In this episode we talk to Dr Jan Verbakel who is a GP and professor of primary care at Leuven.Paper: GPs’ perspectives on diagnosing childhood urinary tract infections: a qualitative studyhttps://doi.org/10.3399/BJGP.2021.0589Diagnosis of childhood UTIs is challenging in the outpatient setting. GP’s perspectives for the diagnostic workup of childhood UTIs are not well understood. In this study, we found that assuming low UTI prevalence, the aspecific presentation of UTI in children and difficulties in urine collection were barriers for diagnosis of childhood UTI. Diagnostic uncertainty makes appropriate treatment challenging. Factors that might improve the diagnostic workup were: novel noninvasive collection techniques, instructional material for the parents, skill training for GPs, decision support tools, accurate and easy-to-use point-of-care tests and guidance on urine culture interpretation.

In this episode we talk to Dr Meena Rafiq who is an academic GP and clinical research fellow at University College London.Paper: Inflammatory marker testing in primary care in the year before Hodgkin lymphoma diagnosis: a UK population-based case–control study in patients aged ≤50 yearshttps://doi.org/10.3399/BJGP.2021.0617Understanding the timing of the inflammatory response in Hodgkin lymphoma may help identify opportunities for earlier diagnosis. In patients with Hodgkin lymphoma presenting to U  K general practice, greater than expected and increasing use of inflammatory marker tests in the year before diagnosis were observed; two-thirds of patients with Hodgkin lymphoma who were tested for inflammatory markers had abnormal results, with almost half of patients in this group having no other recorded red-flag feature beyond their abnormal result. These findings provide proof of concept about the presence of a ‘diagnostic window’ during which Hodgkin lymphoma diagnosis could be expedited in at least some patients. Given the challenges of timely diagnosis in patients with Hodgkin lymphoma, inflammatory marker testing could help to expedite the diagnosis in those presenting with non-specific symptoms if supported and utilised by future advances in diagnostic technology.

In this episode we talk to Dr Sean MacBride-Stewart who is Lead Pharmacist for Medicines Management Resources, Pharmacy Services, NHS Greater Glasgow and Clyde.Paper: Feedback of actionable individual patient prescription data to improve asthma prescribing: pragmatic cluster randomised trial in 233 UK general practiceshttps://doi.org/10.3399/BJGP.2021.0695Prescribing feedback to GPs is a common intervention but evidence suggests that alone it is not very effective in changing behaviour. We investigated whether newly available patient-level prescription data could be used to measure potentially inappropriate prescribing (PIP) of bronchodilators. This pragmatic study found patient-level feedback to GPs was effective at reducing the number of patients exposed to excess or unsafe prescribing of bronchodilator inhalers. This would be feasible to implement, at scale, where primary care electronic prescribing is in general use.

In this episode we talk to Dr Jessica Watson who is a GP and NIHR Academic Clinical Lecturer, Centre for Academic Primary Care at the University of Bristol.Paper: ‘I guess I’ll wait to hear’: a qualitative study of communication of blood test results in primary carehttps://doi.org/10.3399/BJGP.2022.0069Previous studies have shown that failure to communicate or action blood tests can lead to patient harms, with delay in diagnosis being the commonest cause of malpractice claims in primary care worldwide. This study found that systems of test result communication vary between doctors and are often based on habits, unwritten heuristics, and personal preferences rather than protocols. Doctors generally expect that patients know how to access their test results, and assume that patients will proactively seek out their test results, with implications for patient safety. Practices have an ethical and medicolegal obligation to ensure they have robust systems for test communication.

In this episode we talk to Dr Anita Lim who is a Senior Research Fellow, School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King’s College London.Paper: Non-speculum clinician-taken samples for HPV testing: a cross sectional study in older womenhttps://doi.org/10.3399/BJGP.2021.0708Speculum use is a significant barrier to cervical screening and can become particularly uncomfortable after the menopause. Self-sampling is an obvious solution but does not appeal to all women. Having a doctor or nurse take a sample without a speculum is another possibility but the test performance has not yet been examined. We found HPV testing on non-speculum clinician-taken samples to have comparable test performance to self-sampling, representing a promising new approach for cervical screening.

In this episode we talk to Dr Sarah Price who is a research fellow at the University of Exeter Medical School.Paper: Intra-abdominal cancer risk with abdominal pain: a prospective cohort primary care studyhttps://doi.org/10.3399/BJGP.2021.0552Abdominal pain is a non-specific symptom, which may portend serious disease, including intra-abdominal cancers. There is no unified pathway for investigation. This paper reports the 1-year cumulative incidence risk of intra-abdominal cancer with or without concurrent clinical features for men and women aged 40–59, 60–69 and ≥70 years. Results show that patient demographics and type of concurrent feature effects the cancer risk. These results will inform appropriate testing strategies and specialist referral.

In this episode we talk to Dr Yin Zhou who is a GP and Clinical Research Fellow at the Primary Care Unit, Department of Public Health and Primary Care, at the University of Cambridge.Paper: Pre-diagnostic clinical features and blood tests in patients with colorectal cancer: a retrospective linked data studyhttps://doi.org/10.3399/BJGP.2021.0563Understanding pre-diagnostic patterns of relevant clinical features and abnormal blood test results in patients with colon and rectal cancer could elucidate windows of opportunity during which more timely investigations and referrals could be performed, and earlier diagnosis of cancer could be achieved. We found that consultation rates increased in the year leading up to diagnosis for relevant clinical features such as low haemoglobin, rectal bleeding and change in bowel habits, as well as non-specific blood tests, from as early as 9-10 months before diagnosis. Our findings suggest that potential opportunities for more timely use of cancer investigations or referral exist, and could improve diagnostic pathways, expediting diagnosis and treatment for some patients with colorectal cancer.

In this episode we talk to Dr Kimberley Foley who is a Research Associate at the Department of Primary Care and Public Health, Imperial College London.Paper: Impact of Covid-19 on primary care contacts with children and young people aged 0-24 years in England; longitudinal trends study 2015-2020https://doi.org/10.3399/BJGP.2021.0643The Covid-19 pandemic response led to health system reorganisation globally, but its impact on children and young people’s access to primary care is largely unknown. Children and young people’s health contacts with general practitioners (GPs) fell by 41%, equivalent to 2.8 million fewer contacts in England, during the first Covid-19 pandemic lockdown from March to June 2020 compared with the previous 5 years.Face-to-face contacts with GPs fell by 88% with a corresponding increase in remote contacts. The greatest falls in face-to-face contacts occurred among children aged 1-14 (> 90%). Remote contacts with infants and with young people aged 15-24 years more than doubled, mitigating some of the total falls in these age groups.GP contacts for respiratory illnesses fell 74% during lockdown compared with previous years, while contacts for common non-transmissible conditions (urinary tract infections, appendicitis, diabetes, and epilepsy) had a lesser fall at 31%.

In this episode we talk to Dr Rohini Mathur who is an associate professor of epidemiology at the London School of Hygiene and Tropical Medicine and Dr Sally Hull who is a GP and a member of the Clinical Effectiveness Group at QMUL. Paper: Characterisation of type 2 diabetes subgroups and their association with ethnicity and clinical outcomes: a UK real-world data study using the East London Databasehttps://doi.org/10.3399/BJGP.2021.0508Previous studies of predominantly White European populations have identified four type 2 diabetes subgroups. In the UK the clinical measures necessary to replicate these subgroups are only available in secondary care data, limiting their usefulness for diabetes management in primary care settings. The current study demonstrated how clinically meaningful type 2 diabetes subgroups can be pragmatically generated using real-world primary care data. Furthermore, it highlighted important differences between type 2 diabetes subgroups with respect to vascular outcomes, treatment initiation, and glycated haemoglobin control. Diabetes subgroups are a useful heuristic for assisting decision making by clinicians that, in turn, can lead to a more personalised design of diabetes care focused on more intensive management of subgroups most at risk of complications, such as those with severe hyperglycaemia at time of diagnosis.

In this episode we talk to Dr David Whiteley who is a lecturer at the Department of Nursing and Community Health, School of Health and Life Sciences, Glasgow Caledonian University.Paper: Developing a primary care-initiated hepatitis C treatment pathway in Scotland: A qualitative studyhttps://doi.org/10.3399/BJGP.2022.0044Historically, GPs were rarely involved in the treatment of HCV, their role more commonly restricted to viral testing and diagnosis. Contemporary drug therapy for HCV has allowed reconsideration of this status quo, and offers potential for GPs to initiate HCV treatment in primary care. This study provides a way forward, detailing a practicable theory-informed pathway and recommendations for primary care-initiated HCV treatment in the UK.

In this episode we talk to Amy Clark who is a final year medical student at Cardiff and Dr Kathryn Hughes who is a GP and senior clinical lecturer at PRIME Centre Wales at the School of Medicine at Cardiff University.Paper: Accuracy of the NICE traffic light system in children presenting to general practice: a retrospective cohort studyhttps://doi.org/10.3399/BJGP.2021.0633The National Institute for Health and Care Excellence (NICE) traffic light system is widely used in general practice for the assessment of unwell children; however, the majority of previous studies validating this tool have been conducted in secondary care settings. To that authors’ knowledge, no studies have validated this tool within UK general practice. This study found that the traffic light system cannot accurately detect or exclude serious illness in children presenting to UK general practice with an acute illness. The conclusion reached was that it cannot be relied on by clinicians for the assessment of acutely unwell children and that it is unsuitable for use as a clinical decision tool.

In this episode we talk to Dr Jon Gibson who is a research fellow at the School of Health Sciences at the University of Manchester.Paper: Primary care workforce composition and population, professional, and system outcomes: a retrospective cross-sectional analysishttps://doi.org/10.3399/BJGP.2021.0593The increasing number of staff from diverse healthcare backgrounds is changing the general practice workforce in England. These changes provide a new opportunity to investigate whether, and how, workforce composition may be associated with outcomes. This analysis indicated that professional, population, and system outcomes show a variety of associations with primary care workforce composition. The findings demonstrated that different types of health professionals are not substitutes for each other, and the quantity and quality of primary care services delivered will depend on who is employed to work in this setting.

In this episode we speak to Professor Chris Butler who is a GP and professor of primary care at the Nuffield Department of Primary Care Health Science at the University of Oxford. He is also Co-Chief Investigator for the PRINCIPLE trial and the PANORAMIC trial.Paper: Colchicine for COVID-19 in the community (PRINCIPLE): a randomised, controlled, adaptive platform trialhttps://doi.org/10.3399/BJGP.2022.0083Colchicine has been proposed as treatment for COVID-19 due to its anti-inflammatory properties, but evidence to support its use is inconclusive, and its effect on time to recovery in the community has not been evaluated. The RECOVERY trial found no benefit with colchicine use among people hospitalised with COVID-19, while the COLCORONA trial found some evidence of a 1.1% and 1.4% absolute reduction in hospitalisations/deaths among adults with suspected or confirmed COVID-19 in the community respectively. In this national, platform adaptive randomised controlled trial, we found evidence of no meaningful benefit with colchicine on time to recovery, and because the threshold for futility on time to recovery was met, randomisation to colchicine was stopped before collecting substantial data on hospitalisations and death, leading to imprecise estimates for that outcome. Our findings add to the evidence currently available and suggest that colchicine should not be recommended for treating symptoms of COVID-19.

In this episode we speak to Dr Charlotte Archer who is senior research associate in primary care mental health at Bristol Medical School at the University of Bristol.Paper: Rise in prescribing for anxiety in UK primary care between 2003 and 2018: a population-based cohort study using Clinical Practice Research Datalinkhttps://doi.org/10.3399/BJGP.2021.0561Previous studies have found substantial increases in the prescribing of antidepressants for any indication, and for depression, over the past two decades.The current study found increases in incident prescribing for anxiety in most anxiolytic drug classes, and an increase in the number of new patients starting treatment is more likely to explain the overall increase rather than increases in long-term use. Increases in prescribing were most notable in young adults, with a marked rise in benzodiazepine prescriptions for this group. Increases in incident prescribing may reflect better detection of anxiety or an earlier unmet need; however, some of this prescribing is not based on robust evidence of effectiveness, some may contradict guidelines, and there is limited evidence on the overall impact associated with taking antidepressants long term, and therefore, there may be unintended harm.

In this episode we talk to Dr Laura Jefferson who is a Research Fellow at the Department of Health Sciences at the University of York.Paper: General practitioner wellbeing during the COVID-19 pandemic: A systematic review.https://doi.org/10.3399/BJGP.2021.0680Many GPs have reported stress and burnout over recent years, which is potentially damaging not just to doctors themselves, but also to patients and healthcare systems. The coronavirus pandemic has presented new challenges and there is a need to evaluate the impact on GP wellbeing. This review synthesises the international evidence base exploring primary care doctors’ psychological wellbeing during the pandemic. Studies have highlighted multiple sources of stress during this time and reported experiences of stress, burnout, anxiety, depression, fear of COVID, reduced job satisfaction and physical symptoms. Gender and age differences may warrant further research to identify interventions targeted to the needs of specific groups.

In this episode we interview Dr Austin O'Carroll who is a GP based in Dublin and founder of Safetynet Ireland and North Dublin City GP Training, and co-founder GPCareForAll.Paper: The Triple F**k Syndrome: How medicine contributes to the systemic oppression of people born into povertyLink to article: https://bjgplife.com/the-triple-fk-syndrome-how-medicine-contributes-to-the-systemic-oppression-of-people-born-into-poverty/Austin argues that the label of personality disorder is inappropriate and harmful to patients who have suffered adverse social environments in childhood. By simultaneously ignoring social causation and denying the possibility of therapy the diagnosis perpetrates a systematic injustice against those who are labelled.

In this episode we talk to Dr Simon Fraser who is an associate professor of public health at the School of Primary Care at the University of Southampton.Paper: Persistently normal blood tests in patients taking methotrexate for RA or azathioprine for IBD: a retrospective cohort studyhttps://doi.org/10.3399/BJGP.2021.0595Clinical guidance from the National Institute for Health and Care Excellence recommends 3-monthly blood-tests for the ongoing safety monitoring of conventional synthetic disease-modifying anti-rheumatic drugs, but questions have been raised about the need for this testing frequency. Using 2 years’ data from a large primary care database, this study found that persistent normality of blood-test results was common and abnormalities were dominated by reduced renal function among older people, with relatively few hepatic or haematological abnormalities. Greater stratification of monitoring may reduce workload and costs for patients and health services, but more evidence is required on the long-term safety, acceptability, and cost-effectiveness of changing current practice.BJGP research on optimising primary care research dissemination: an online surveyERGO number: 70228.A1We would like to find out how often practising GPs and GP trainees access primary care research (in any form), and how we could improve its dissemination.We are very much interested in the views of those who don't access research regularly, as well as those who do.We would therefore be very grateful if you could consider completing a short online survey which will take less than 5 minutes to complete.If you are willing to participate, please access the survey via this link: https://southampton.qualtrics.com/jfe/form/SV_bIRKhaA0CrmZJ3w

In this episode we talk to Professor Trisha Greenhalgh from the Nuffield Department of Primary Care Health Sciences at the University of Oxford.Paper: Why do GPs rarely do video consultations? A qualitative study in UK general practicehttps://doi.org/10.3399/BJGP.2021.0658The pandemic provided strong impetus to extend remote consultation services in general practice, but video remains infrequently used. This study used in-depth case study methods to explore the multiple interacting influences on the non-adoption and abandonment of video consulting in general practice. Telephone was considered adequate for most remote consultations; the need for a hands-on physical examination explained why video rarely replaced in-person assessment in the remainder.

In this episode we talk to Dr Christo Karuna who is a Senior Lecturer at Monash University, Australia. Paper: Prevalence of burnout among general practitioners: a systematic review & meta-analysishttps://doi.org/10.3399/BJGP.2021.0441GP burnout is widely recognised as a problem in health care. However, no study has been conducted on the global burden of this condition. The systematic review and meta-analysis conducted in this study show that moderate to high levels of burnout exist worldwide. However, a challenge to policy makers is the wide variation in burnout estimates across studies and countries documented in this review. The findings from this review highlight that the context within which GPs work should be considered in better understanding GP burnout.

In this episode we talk to Mr Ashu Gandhi who is a consultant surgeon from Wythenshawe Hospital in Manchester and an honorary senior lecturer at the Manchester Breast Centre at the University of Manchester.Paper: No association between breast pain and breast cancer: A prospective cohort study of 10,830 symptomatic women presenting to a breast cancer diagnostic clinichttps://doi.org/10.3399/BJGP.2021.0475zWomen with breast pain are often anxious that this symptom may represent an underlying breast malignancy and are consequently referred to secondary care to exclude this diagnosis. This study shows that the incidence of breast cancer in women with breast pain alone (no associated symptoms such as breast lumps or nipple discharge) is 0.4%, a figure similar to that seen in asymptomatic women invited for breast screening. Economic analysis confirms that referral of women with breast pain alone to secondary care diagnostic clinics is associated with increased cost but no additional health benefits. Women with breast pain should be reassured that they are at no greater risk of breast cancer than asymptomatic women.

In this episode we talk to Dr Hassan Awan who is a GP and Wellcome Doctoral Fellow at the School of Medicine, Keele University.Paper: Emotional distress, anxiety and depression in South Asians with long-term conditions: a qualitative systematic reviewhttps://doi.org/10.3399/BJGP.2021.0345Mental health is reported to be poorer among people with long-term conditions (LTCs) and people of South Asian origin, but little is known about their experiences. This research adds that people of South Asian origin with long-term conditions describe emotional distress using non-medical terminology, even when describing suicidality. This may be related to their cultural understanding of the world. We highlight the importance of cultural competence to prevent clinicians from being viewed as not understanding the patient, and irrelevant as a means of support.

In this episode we talk to Dr Joāo Delgado who is a lecturer in Epidemiology and Public Health, College of Medicine and Health at the University of Exeter.Paper: Continuity of general practitioner care for patients with dementia: impact on prescribing and the health of patientshttps://doi.org/10.3399/BJGP.2021.0413Evidence is limited about the potential positive effects of higher continuity of general practice care (CGPC) in patients with dementia. There is no cure for dementia, so finding elements of care that make a difference to patients remains a priority. Patients with dementia in the highest CGPC quartile were 34.8% less likely to develop delirium, 57.9% less likely to develop incontinence, and 9.7% less likely to have an emergency admission to hospital, compared with the lowest quartile. Higher continuity of care was also associated with lower medication burden and fewer potential inappropriate prescriptions.

In this episode we talk to Professor Jeremy Horwood who is a professor of social sciences and applied health research at NIHR ARC West, and the Centre for Academic Primary Care, at the University of Bristol.Paper: Unintended consequences of online consultations: a qualitative study in UK primary carehttps://doi.org/10.3399/BJGP.2021.0426Previous studies have shown that online consultations may be best for straightforward transactions such as simple and administrative queries, but do not necessarily deliver improvements in access to care or practice efficiency. This qualitative study identified unintended consequences of a range of online consultation tools that negatively impacted patients’ ability to communicate effectively with a GP, access to care, practice workload, and staff satisfaction. These consequences were often operational challenges that could be foreseen and prevented; however, the tools also had consequences that favoured simple, remote transactions and a shift away from holistic face-to-face care.

In this episode we talk to Dr Gail Hayward who is a GP and Associate Professor of Primary Care at the Nuffield Department of Primary Care Health Sciences, University of Oxford.Paper: Urine collection devices to reduce contamination in urine samples for diagnosis of uncomplicated UTI: a single-blind randomised controlled trial in primary carehttps://doi.org/10.3399/BJGP.2021.0359This trial is the first to evaluate the effectiveness of urine collection devices in the population of most relevance: women with symptoms of UTI presenting to primary care. Neither device tested reduced sample contamination when used by women presenting to primary care with symptoms attributable to uncomplicated UTI. Since there are no other studies in this population, their use cannot be recommended for this purpose in this setting.

In this episode we talk to Dr Stephen Bradley who is a GP and clinical research fellow at the University of Leeds.Paper: Associations between general practice characteristics and chest X-ray rate: an observational studyhttps://doi.org/10.3399/BJGP.2021.0232Abnormal findings on chest X-rays that have been requested by GPs because of symptoms are an important route to lung cancer diagnosis. Previous research has suggested that increased rates of chest X-ray and urgent referral for suspected cancer may be associated with earlier stage at diagnosis for lung cancer. This study demonstrates that there is substantial variation in rates of investigation between practices, and that only a small proportion of that variation is owing to examined population and practice characteristics. Encouraging practices that have low chest X-ray rates to lower their thresholds for investigation could prove to be an effective strategy to detect lung cancer earlier and improve outcomes.Relevant referencesStudies by CanTest Leeds team on CXR discussed in the podcastSystematic Review on sensitivity CXR: https://bjgp.org/content/69/689/e827Observational study on sensitivity of CXR: https://bjgp.org/content/71/712/e862Estimating risk of lung cancer following negative CXR: https://bjgp.org/content/71/705/e280Observational study on frequency of CXR use and practice/population characteristics: https://bjgp.org/content/72/714/e34Remaining uncertainty regarding whether increasing GP CXR rates leads to improved outcomesLung cancer stage shift following a symptom awareness campaign (Kennedy) https://thorax.bmj.com/content/73/12/1128What characteristics of primary care and patients are associated with early death in patients with lung cancer in the UK? (O'Dowd )https://thorax.bmj.com/content/70/2/161Lung cancer screening and the place for ongoing sympatomatic detection alongside asymptomatic screeningThe proportion of lung cancer patients attending UK lung cancer clinics who would have been eligible for low-dose CT screening (Gracie) https://erj.ersjournals.com/content/54/2/1802221What is the balance of benefits and harms for lung cancer screening with low-dose computed tomography?  (Bradley) https://journals.sagepub.com/doi/full/10.1177/0141076821991108Views expressed on the future of lung cancer imaging policy and research in the UKEvidence submitted to health & social care parliamentary select committee inquiry on cancer services (Bradley) https://committees.parliament.uk/writtenevidence/38850/pdf/

In this episode we talk to Dr Christos Grigoroglou and Professor Kieran Walshe. Christos is a Research Fellow in Health Services Research, Manchester Centre for Health Economics and Kieran is a Professor of Health Policy and Management both at the University of Manchester.Paper: The scale and scope of locum doctor use in general practice in England: Analysis of routinely collected workforce data in 2017-2020https://doi.org/10.3399/BJGP.2021.0311Prior research on the extent of GP locum use in general practice and the composition of the GP locum workforce is sparse, and the availability of new data from general practice allows for a real opportunity to generate new knowledge and to add to the understanding of the current GP workforce composition. Results of the study suggest that GP locum use has remained stable over time and our comparisons of GP locums with other types of GPs show that locums are mostly younger male doctors of whom a large proportion have qualified elsewhere than the UK and who work in underperforming practices. Substantial regional variation in GP locum use across England indicate differences in workforce planning, recruitment and retention. This work provides a useful approach to measure the extent of locum use in primary care and can aid workforce planning by identifying areas of increased recruitment, areas with high GP turnover and also the drivers behind variation in locum use in primary care in England.

In this episode we speak to Dr Anita Lim who is a Senior Research Fellow, School of Cancer and Pharmaceutical Sciences at King’s College London.Paper: Non-speculum sampling approaches for cervical screening in older women: randomised controlled trialhttps://doi.org/10.3399/BJGP.2021.0350Inadequately screened women aged 50 and older are at a disproportionately higher risk of cervical cancer and dying from it. Speculum use is a major barrier to cervical screening and can become more uncomfortable with ageing and the menopause. Although self-sampling has been hailed as a game-changer for cervical screening, it does not appeal to all women. This study showed that offering a choice of non-speculum clinician sampling or self-sampling substantially increased cervical screening uptake in older lapsed attendees across all ethnicities, an approach which could be easily implemented into existing practice in primary care.

In this episode we talk to Dr Iona Heath, a retired GP from Kentish Town and former President of the RCGP. She talked to us after writing an editorial for the BJGP. She discusses the current crisis in UK general practice and offers an approach that can tackle some of the deep-rooted problems we face. The editorial: Rewilding general practice.Paper: https://doi.org/10.3399/bjgp21X717689

In this episode we talk to Dr Jordan Moxey and Dr Carol Sinnott who are both at the Department of Public Health and Primary Care, The Healthcare Improvement Studies Institute in Cambridge. Jordan is a medical doctor and programme coordinator. Carol is a Senior Clinical Research Associate and GP.Paper: Identifying how GPs spend their time and the obstacles they face: a mixed-methods studyhttps://doi.org/10.3399/BJGP.2021.0357Direct observations of what consumes GPs’ time and what might disrupt their ability to complete tasks have remained remarkably rare. Operational failures are common in general practice and highly consequential. Frequent operational failures include interruptions interfering with task completion, problems relating to equipment and supplies, problems arising from GPs’ coordination role, and defects in organisational processes within practices. The impact of operational failures in general practice goes well beyond diversion of time and interference with task completion: they are very adverse for GPs’ experiences of work.

PLAYERIn this episode we speak to Dr Claire Friedemann Smith who is a senior researcher at the Nuffield Department of Primary Care, University of OxfordPaper: Building the case for the use of gut-feelings in cancer referrals: perspectives of patients referred to a non-specific symptoms pathwayhttps://doi.org/10.3399/BJGP.2021.0275Despite the reported diagnostic utility for cancer of GPs’ gut feelings and the role they may play in facilitating diagnosis through prompting investigation, research has not explored the use of gut-feelings in clinical decision making with patients. Our study found that patients were supportive of the use of gut-feelings if they facilitated investigations but cautioned against their use if it meant that investigations would be deferred or denied. Patients discussed the difficulty facing GPs of having to fit individuals to referral ‘tick boxes’ in order to make a referral, were aware of the time pressured and resource limited conditions of primary care practice, and raised these as reasons for why GPs’ use of gut-feelings is justified. Patients share GPs’ concerns around gut-feelings overburdening NHS resources and increasing the risk of negligence and litigation and these should be investigated.

In this episode we speak to Professor Helen Snooks who is Professor of Health Services Research in the Medical School at Swansea University in Wales.Paper: Implementing emergency admission risk prediction in general practice: a qualitative studyhttps://doi.org/10.3399/BJGP.2021.0146UK policy has incentivised use of risk prediction stratification in primary care to reduce emergency hospital admissions, despite lack of evidence about process or effect. In a trial evaluating a risk prediction tool (PRISM) in general practice, our team reported increased emergency and hospital admissions. To understand implementation, we interviewed GPs and Practice Managers who reported using PRISM on a small group of high-risk patients. Although they doubted any impact on care, they said PRISM raised their awareness of highest-risk patient groups, which potentially may affect unplanned hospital attendance and admissions.

In this episode we speak to Dr Lucy Martin who is a GP at Eve Hill Medical Practice in Dudley in the West Midlands.Paper: The professional resilience of mid-career GPs in the UK: a qualitative studyhttps://doi.org/10.3399/BJGP.2021.0230In this study, GPs identify ‘good’ mid-career resilience and protective factors such as social support, which concurs with existing research. The novel contribution is the identification of clear factors that reduce the professional resilience of GPs in the UK. A GP with strong resilience may exhibit obstructive work behaviours and surface acting to demonstrate resilience. Resilience has become another work task for GPs. Social media, despite being intended to be supportive, can act as a drain on resilience.

In this episode we speak to Dr Patrick Highton who is a Research Associate at the Diabetes Research Centre at the University of Leicester and also part of the NIHR Applied Research Collaboration East Midlands.Paper: Promoting physical activity through group self-management support for those with multimorbidity: a randomised controlled trialhttps://doi.org/10.3399/BJGP.2021.0172People with multimorbidity typically display increased morbidity and mortality risk, driven in part by reduced levels of habitual physical activity. Disease self-management empowers patients to take more of an active role in their own healthcare and has shown promise in individual conditions, though this is under-researched in multimorbidity. This study investigated the impact of a targeted group-based disease self-management programme on habitual physical activity levels in people with multimorbidity. However, a slight decrease in physical activity levels was observed, suggesting that the intervention was ineffective, and that future research should target those at greatest need for physical activity intervention.

In this episode we speak to Dr Alex Walker who is an epidemiologist at the Nuffield Department of Primary Care Health Sciences, University of Oxford.Paper: Clinical coding of long COVID in English primary care: a federated analysis of 58 million patient records in situ using OpenSAFELYhttps://doi.org/10.3399/BJGP.2021.0301Early case definitions and clinical guidelines have been published to describe long COVID, and clinical codes based on these guidelines were published in late 2020. This study found wide variation in the early use of these codes, by practice, geographic region, and practice electronic health record software. Promotion of the clinical guidance and codes is important for future research and ongoing patient care.

In this episode we talk to Dr Hogne Sandvik who is a senior researcher at the National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Bergen.Paper: Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norwayhttps://doi.org/10.3399/BJGP.2021.0340Continuity of care with a GP is generally regarded as an aspect of quality. It is usually measured by visit patterns with different providers over time and is associated with lower mortality rates, fewer hospital admissions, and less use of emergency departments. This nationwide study of the Norwegian population shows that longitudinal continuity with a named regular GP is significantly associated with the need for out-of-hours services, acute hospital admissions, and mortality in a dose-dependent way. When longitudinal continuity exceeds 15 years, the probability of these occurrences is reduced by 25–30%.

In this episode we talk to Professor Brendan C Delaney who is a GP partner and Chair in Medical Informatics and Decision Making at Imperial College London.Paper: Recommendations for the recognition, diagnosis, and management of long Covid: A Delphi studyhttps://doi.org/10.3399/BJGP.2021.0265There is an urgent need to devise clinical pathways and guidance for long Covid (thought to affect 10% of those diagnosed with Covid-19). In the absence of conclusive research to inform clinical practice, “expert physician-patients” (i.e., doctors with long Covid and those involved in nascent clinics) are a source of professional expertise. Using robust consensus methodology, we derived 35 clear and practical recommendations to assist in the organisation of clinics, and the diagnosis and management of patients with long Covid. Medically-led multidisciplinary clinics are required as serious cardiovascular, neurocognitive, respiratory and immune sequelae such as can present with only non-specific symptoms.

In this episode we speak to Dr Thomas Round who is a GP in East London and NIHR doctoral research fellow. Paper: Cancer detection via primary care urgent referral and association with practice characteristics: a retrospective cross-sectional study in England from 2009/2010 to 2018/2019https://doi.org/10.3399/BJGP.2020.1030There is considerable variation in the use of urgent suspected cancer referrals (2-week wait [2WW]) between general practices in England, with increased use associated with improved outcomes for patients with cancer. There has been limited research into the practice and population characteristics associated with cancer detection via 2WW referral pathways. Over the 10-year period up to 2018/2019, yearly 2WW referrals more than doubled to more than 2.24 million, leading to an increase in cancer detection and 66,172 additional cancers diagnosed via 2WW in 2018/2019 compared with 2009/2010. Higher cancer detection via 2WW referrals was associated with larger practices and those with younger GPs, although the relationship with GP age was attenuated in more recent years. Of concern are decreases in 2WW referrals during the COVID-19 pandemic and the appearance of potential disparity in cancer detection, with lower rates in practices that serve more deprived populations.

In this episode we talk to Professor Stewart Mercer who is a Professor of Primary Care and Multimorbidity at the Usher Institute, College of Medicine and Veterinary Medicine at the University of Edinburgh.Paper: Implementing social prescribing in primary care in areas of high socioeconomic deprivation: process evaluation of the ‘Deep End’ community links worker programmehttps://doi.org/10.3399/BJGP.2020.1153Social prescribing using primary care-based link workers is increasingly promoted across the four nations of the UK and elsewhere in the world, as a way of reducing health inequalities by better supporting people living in deprived areas. However, the evidence-base of effectiveness is limited, and there is very little information on how best to successfully implement a link worker approach in practice.This study reports on a process evaluation of the ‘Deep End’ Links Worker Programme (LWP) over a two-year period, in seven general practices in deprived areas of Glasgow. Despite the programme being well-funded and well supported, the majority of practices involved had not fully integrated the LWP within the first two 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.

In this episode we talk to Dr Peter Edwards who is a GP and academic clinical fellow at the Centre for Academic Primary Care at the University of Bristol Medical School.Paper: Factors affecting the documentation of spoken safety-netting advice in routine GP consultationshttps://doi.org/10.3399/BJGP.2021.0195Previous research has provided qualitative insights into how GPs document safety-netting advice and there have been quantitative reports of the binary presence or absence of safety-netting in medical records. This is the first study to undertake a detailed analysis of the content of documented safety-netting advice and make objective comparisons to what was spoken in recorded consultations.GPs more frequently documented their safety-netting advice if it was specific (e.g. “I’d want you to come back if you start coughing up horrid coloured stuff, greeny-browny, or if you start coughing up any blood, or if you feel more short of breath.”) rather than generic advice (e.g. “any problems let me know”), for a new problem, and for problems that were the entire focus of a consultation.These trends in GP documentation practices highlight that certain consultations, such as those where multiple problems are assessed, may represent a higher medico-legal risk to GPs due to incomplete documentation, and these potential biases should be considered in medical-records based research.

In this episode we speak to Anouk Weghorst who is a doctoral candidate in the Department of General Practice and Elderly Care Medicine, University of Groningen, Netherlands.Paper: Oral ondansetron for paediatric gastroenteritis in primary care: a randomised controlled trialhttps://doi.org/10.3399/BJGP.2021.0211Ondansetron was found to be effective in reducing vomiting in secondary care, but this effect has never been evaluated in primary care. Based on the findings of this study, ondansetron use is effective in reducing vomiting from 42.9% to 19.5%, seems safe and is positively evaluated by parents. Therefore, ondansetron could be considered by general practitioners as an additional treatment in the management of dehydration due to acute gastroenteritis, when the child predominantly vomits. Future research should disentangle the key factors leading to hospital referrals and consider ways to administer ORT more effectively in primary care or at home.

In this episode we speak to Professor Adrian Edwards who is Professor of General Practice and Director of PRIME Centre Wales and Director of Wales Covid-19 Evidence Centre at Cardiff University.Paper: Managing lower urinary tract symptoms in primary care: qualitative study of GPs’ and patients’ experienceshttps://doi.org/10.3399/BJGP.2020.1043Lower urinary tract symptoms (LUTS) in males can usually be treated effectively in primary care; however, referrals to urology services are increasing. This study explores in detail the experiences of GPs and patients in relation to the management of LUTS in primary care. Difficulty establishing causes and differentiating symptoms were identified as key challenges; therefore, treatment was often a process of trial and error, and no patient’s symptoms were completely resolved. A diagnostic tool for use by GPs, together with greater exploration of non-pharmacological treatment approaches, could support effective management of LUTS in primary care settings.This study aimed to explore GPs’ experiences of diagnosing and managing LUTS, together with patients’ experiences of and preferences for treatment of LUTS in primary care. Tell us a little more about the background to theTelephone interviews were conducted with GPs and patients from GP practices involved in the PriMUS (Primary care Management of lower Urinary tract Symptoms in men: development and validation of a diagnostic and clinical decision support tool) study16 across three UK regions: Newcastle upon Tyne, Bristol, and South Wales. PriMUS is a prospective diagnostic accuracy study aimed at developing a decision tool to help GPs more accurately diagnose and manage LUTS in males.

In this episode we talk to Dr Sharon Dixon, GP and researcher, at the Nuffield Department of Primary Care Health Sciences, University of Oxford. The research was funded by the NIHR School of Primary Care Research.Paper: Navigating possible endometriosis in primary care: a qualitative study of GP perspectiveshttps://doi.org/10.3399/BJGP.2021.0030There are documented time lags between women presenting to primary care with symptoms suggesting endometriosis and receiving a diagnosis. It has been suggested that increasing GPs awareness will improve this situation. As GPs perspectives on these care journeys are not known, how best to educate health professionals to reduce delays in diagnosis is unclear. Even with awareness of the possibility of endometriosis, GP accounts suggest that journeys are complex and can involve navigating significant uncertainties, including when managing women whose symptoms are well controlled with primary care treatment or who do not want to have referral or operative investigation.

In this episode we speak to Dr Faraz Mughal who is a National Institute for Health Research (NIHR) doctoral fellow at Keele University.Paper: Experiences of general practice care for self-harm: a qualitative study of young people’s perspectiveshttps://doi.org/10.3399/BJGP.2021.0091Young people who self-harm present to GPs in the NHS, but their perceptions of care remain largely unexplored. This qualitative study indicated that young people sought help from a variety of services, including non-statutory services and NHS services. Young people described mixed experiences of consulting GPs, which can influence help-seeking from general practice. A relationship with one GP who listens, appears to understand, and offers proactive follow-up is an important facilitator for young people who access general practice for self-harm.

In this episode we speak to Dr Ian Bennett-Briton who is a Clinical Research Fellow in Primary Health Care at the Centre for Academic Primary Care at the University of Bristol.Paper: Understanding the benefits and limitations of continuous, risk-based, consultation peer-review in out-of-hours general practice: A qualitative interview studyhttps://doi.org/10.3399/BJGP.2021.0076Unwarranted variation in clinical practice is an area of increasing interest due to the costs and harms of too much or too little healthcare. Effective systems to detect and minimise unwarranted variation in clinician practice are crucial to ensure clinicians in increasingly multidisciplinary healthcare workforces are supported to practise to their full potential. Such systems are limited in English general practice settings, with implications for the efficiency and safety of care. Continuous, risk-based, consultation peer-review provides a mechanism to detect and minimise unwarranted variation in clinician practice, and a potential methodology to support clinicians in an increasingly multidisciplinary general practice workforce to efficiently and safely practise to their full potential.

This episode is a quick update from BJGP Editor, Euan Lawson, as we are taking a break for a couple of weeks and we will back in August with more interviews. We would love you to get involved. Why not write us an article for BJGP Life? Check out the links for more details.BJGP Life Call for Summer articles: https://bjgplife.com/2021/07/26/bjgp-life-call-for-summer-articles/BJGP.org eLetters: https://bjgp.org/lettersSign up for the print BJGP: https://www.bjgplife.com/print

In this episode we talk to Dr Julian Treadwell who is a GP and doctoral research fellow at the Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Woodstock Road, Oxford.Paper: GPs’ use and understanding of the benefits and harms of treatments for long-term conditions: a qualitative interview studyhttps://doi.org/10.3399/BJGP.2020.1027Research has shown that doctors, including GPs, often have poor knowledge of quantitative benefits and harms of treatments, such as absolute risk reduction and numbers needed to treat. Yet this kind of information is considered key to shared decision making and optimal management of polypharmacy. This qualitative study explored the attitudes and understanding of GPs in the UK with regard to this issue, and reveals a complex set of behaviours and feelings. These findings will be of interest to doctors wishing to reflect on their own practice, and to authors of guidelines and information resources.Linkshttps://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/shared-decision-making 

In this episode I speak to Dr Marta Wanat who is a Senior Qualitative Researcher at the Nuffield Department of Primary Care Health Sciences, University of Oxford.Paper: Transformation of primary care during the COVID-19 pandemic: experiences of healthcare professionals in eight European countrieshttps://doi.org/10.3399/BJGP.2020.1112Previous qualitative studies exploring the experiences of healthcare professionals during the COVID- 19 pandemic have mainly focused on secondary care. This study explored the experiences of primary care healthcare professionals’ (PCPs) experiences of primary care transformation during the first peak of COVID-19 pandemic in England, Belgium, the Netherlands, Ireland, Germany, Poland, Greece and Sweden. PCPs described rapidly adapting to new circumstances by making decisions in how to transform primary care delivery for both COVID-19 and non-COVID-19 patients, with limited training and resources. Flexibility and autonomy are necessary ingredients in primary care provision that should be preserved, coupled with provision of practical information on how to adapt services, ongoing training, and mental health support services for PCPs.

In this episode I am joined by our Associate Editor Dr Nada Khan for some conversation. The July issue has been published and we talk over some of the highlights in this month's issue.JULY ISSUE: https://bjgp.org/content/71/708

In this episode we have two guests from Australia. We have Erin Oldenhof who is a doctor of psychology (clinical) candidate, at the School of Psychology, Deakin University, Geelong and a benzodiazepine counsellor in Melbourne. We are also joined by Dr Petra Staiger who is an associate professor, School of Psychology, Deakin University.Paper: Role of the prescriber in supporting patients to discontinue benzodiazepines: a qualitative studyhttps://doi.org/10.3399/BJGP.2020.1062The introduction of prescription monitoring programmes (PMPs) has highlighted the need for increased support and guidance to ensure GPs improve on current deprescribing practice. This study revealed the importance of GPs understanding how to empower patients through patient-centred care, to foster a willingness to try reducing, build motivation, and promote confidence in the patients’ ability to reduce. By understanding the patient experience with their prescriber involved in long-term BZD use, this study advances current knowledge of the ‘patient-centredness’ of deprescribing interventions and offers GPs clearer guidance on how to deliver these strategies effectively.

In this episode we talk to Dr Felicity Knights who is a GP Academic Clinical Fellow at The Migrant Health Research Group, Institute for Infection and Immunity, St George’s, University of London.Paper: Impact of COVID-19 on migrants’ access to primary care and implications for vaccine roll out: a national qualitative studyhttps://doi.org/10.3399/BJGP.2021.0028The impact of pandemic-related shifts in primary care delivery on marginalised migrant groups, who may already face major disparities in accessing primary care, is poorly elucidated. We found that the rapid digitalisation of primary care services and physical closure of surgeries during the pandemic have amplified disparities in access to healthcare for specific migrant groups, with many lacking access to and capacity to use technology, compounded by language barriers. Migrants may be at increased risk of misinformation about COVID-19, and face barriers to vaccination, which merits further consideration as COVID-19 vaccine roll out begins. Improved outreach to local migrant community organisations and places of worship, alongside co-designing with migrants more inclusive delivery approaches and creative integration of migrant ambassadors into information- sharing campaigns are needed. Primary care can maximise the opportunities of digitalisation for migrants through flexible engagement by multiple modalities (e.g. text, email, letter and YouTube videos) to provide targeted, translated advice and information, virtual group consultations for patients with a specific condition, and working with local leaders and NGOs to access and disseminate information through informal communication channels.Doctors of the World Safe Surgeries Toolkithttps://www.doctorsoftheworld.org.uk/what-we-stand-for/supporting-medics/safe-surgeries-initiative/safe-surgeries-toolkit/

In this episode we speak to Dr Fiona Cuthill who is a Senior Lecturer, School of Health in Social Science, University of Edinburgh.Paper: An exploration of GP care in outreach settings for people experiencing homelessness: a qualitative studyhttps://doi.org/10.3399/BJGP.2020.0749Although people experiencing homelessness (PEH) have the worst health outcomes in society, they have a low uptake of primary care services. GP outreach has developed as a way of increasing access into primary care but little is known about the experience of patients receiving care in this way. By exploring the experiences of PEH and staff/volunteers working within community outreach settings, this study uncovers the reasons why PEH engage with GPs in a community outreach setting but not a specialist or mainstream GP service. Clearly, physical space and organisational environment are important factors. These findings can help to inform GPs caring for PEH to build an environment which supports the development of stronger doctor-patient relationships within the confines of their current system. 

In this episode we talk to Dr Elizabeth Cecil, Honorary Research Fellow, Department of Primary Care and Public Health, Imperial College LondonPaper: Factors associated with potentially missed acute deterioration in primary carehttps://doi.org/10.3399/BJGP.2020.0986Failure to recognise serious illness (or patient deterioration) can contribute to avoidable harm to a patient. Little is known of determinants of missed deterioration in primary care. GP telephone and video consultations have increased substantially with the COVID-19 pandemic, but these forms of consultations have not been fully evaluated and may increase missed deterioration in primary care.

In this episode we are joined by Remco Tuijt who is a PhD candidate in the Research Department of Primary Care and Population Health, University College LondonPaper: Remote primary care consultations for people living with dementia during the COVID-19 pandemic: experiences of people living with dementia and their carersAvailable at: https://doi.org/10.3399/BJGP.2020.1094Primary care consultations in the United Kingdom have shifted towards remote methods as a result of the COVID-19 pandemic. This qualitative study explores the experiences of and attitudes towards remote consultation through thematic analysis of interviews with people living with dementia and their carers. COVID-19 related check-up calls were found reassuring, albeit somewhat lacking in practical recommendations. Avoidance of healthcare services was reported for numerous reasons, including COVID-19 risk as well as relieving the strain on the NHS. However, when individuals did have remote consultations, these were mostly by telephone and commonly managed by the carer. Primary care professionals engaging with people living with dementia and their carers may need to make extra effort to ensure the efficacy of remote healthcare consultations with patients living with dementia and their carers.

In this episode we are joined by Dr Alison Berner, Clinical Research Fellow in Medical Oncology & Specialty Doctor in Gender Identity Medicine at Barts Cancer Institute, Queen Mary University of London and the Tavistock and Portman NHS Foundation Trust, London, UK.Paper: Attitudes of trans men and non-binary people to UK cervical screeninghttps://doi.org/10.3399/BJGP.2020.0905The UK’s National Health Service cervical screening program has contributed to a 70% reduction in the cervical cancer mortality since 1988. Trans men and non-binary people assigned female at birth (TMNB) experience barriers to accessing adequate cervical screening and are less likely to engage in screening than cisgender women but the attitudes, experiences and behaviours of TMNB as they relate to cervical screening remain unexplored in a UK context. This study indicates that TMNB lack sufficient information about cervical screening and experience barriers to accessing screening services at personal, interpersonal and institutional levels. Cervical screening uptake could be increased by adopting TMNB-appropriate screening invitations, providing options for self-sampling, improving cultural sensitivity in health literature, and improving access to trans-specific or trans-aware health services.

In this episode I am joined by all three of our Associate Editors, Sam Merriel, Tom Round and Nada Khan, for some conversation. The May issue has been published and we talk over some of the highlights in this month's issue.MAY ISSUE: https://bjgp.org/content/71/706

In this episode we speak to Dr Jo Parsons, Research Fellow at Warwick Medical School, University of Warwick.Paper: Which patients miss appointments with general practice and why? A systematic reviewhttps://doi.org/10.3399/BJGP.2020.1017Missed GP appointments have considerable time and cost implications on healthcare services. This review reveals how many booked primary care appointments are missed, reasons given for this, and what characteristics are commonly associated with missed appointments. This has implications for general practices and clinicians aiming to reduce rates of missed appointments, and implementing strategies for this.

In this episode we are joined by Dr Jean-Pierre Laake who was an epidemiologist at Centre for Cancer Prevention at Queen Mary University of London when this research was undertaken but who has now taken up medical training. We are also joined by Professor Willie Hamilton who is Professor of Primary Care Diagnostics at the University of Exeter and also a GP although he has recently dropped his clinical practice.Paper: Targeted encouragement of GP consultations for possible cancer symptoms: a randomised controlled trialhttps://doi.org/10.3399/bjgp20x713489Later stage of cancer diagnosis is associated with poorer survival, and may arise from low symptom awareness and delays in presenting to primary care. Population-wide campaigns to increase awareness and encourage help seeking have shown mixed results in terms of stage at diagnosis and numbers of primary care consultations. This randomised controlled trial was targeted at a population whose circumstances suggested that, should they develop cancer, they would be at increased risk of being diagnosed with later-stage disease. This study demonstrates that targeted interventions of this nature, promoting both awareness of cancer symptoms and earlier health seeking, can change consultation behaviour of those who are likely to benefit most from earlier symptomatic presentation. However, in his study the intervention increased the frequency of consultation but not the number of persons consulting.

In this episode we are joined by Dr Riitta Partanen who is a GP and Associate Professor at the Rural Clinical School, Faculty of Medicine, The University of Queensland in Australia.Paper: GPs’ insights about discontinuing long-term antidepressant use: a qualitative studyhttps://doi.org/10.3399/BJGP.2020.0913Most antidepressant prescriptions are generated in general practice and discontinuation is challenging. Understanding GPs’ insights into decision-making around discontinuing long-term antidepressant use is needed to underpin change. This study points to discontinuation as a journey for the GP-patient dyad that is not a simple deprescribing decision but is built on relationship and grounded in enabling social context.

In this episode&nbsp;I am joined by two of our Associate Editors, Sam Merriel and Tom Round, for some conversation. The April issue has been published and we talk over some of the highlights in this month's issue.APRIL ISSUEhttps://bjgp.org/content/71/705EDITORIAL: Remote by default general practice: must we, should we, dare we? https://doi.org/10.3399/bjgp21X715313EDITORIAL: Helping GPs to diagnose children’s cancer https://doi.org/10.3399/bjgp20X715241LETTER: Prostate-specific antigen testing and opportunistic prostate cancer screening — CAP intervention https://doi.org/10.3399/bjgp20X715361RESEARCH: Diagnosing community-acquired pneumonia via a smartphone-based algorithm: a prospective cohort study in primary and acute-care consultations https://doi.org/10.3399/bjgp.2020.0750RESEARCH: Estimating lung cancer risk from chest X-ray and symptoms: a prospective cohort study https://doi.org/10.3399/bjgp20X713993LIFE &amp; TIMES: Drugs for chronic pain: we still need them https://doi.org/10.3399/bjgp21X715457Visit BJGP Life: www.bjgplife.com/contributeBook mentioned: In Control by Jane Monckton-SmithPSA links mentioned by Sam:https://phescreening.blog.gov.uk/2020/01/20/psa-testing-guidance/https://www.gov.uk/government/publications/prostate-specific-antigen-testing-explanation-and-implementation/advising-well-men-about-the-psa-test-for-prostate-cancer-information-for-gps<a...

In this episode&nbsp;we have a full version of the conversation we had with Professor Sir Michael Marmot. He scarcely needs introduction for his pioneering work on the social determinants of health. As many of you will know we have just passed the 50th anniversary of the publication of the article in which Julian Tudor Hart wrote about the inverse care law.Sir Michael recorded this interview and we used a slightly shorter video version for the opening of our recent BJGP Webinar on health inequalities.If you want to watch the webinar then visit www.bjgplife.com/webinar. The video version is, of course, included with that as well as all the other excellent speakers and panel discussion.

We talk to Dr Claire Friedemann Smith, a senior researcher at the Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford.The paper is: GPs’ use of gut feelings when assessing c&nbsp;ancer risk in primary care: A qualitative studyRead the paper: https://doi.org/10.3399/bjgp21X714269GP’s gut feelings have often been criticised because of their subjective nature. GP’s suggested that they did not rely on gut feelings in isolation but used them as prompts to gather additional clinical evidence to support their decisions and to reduce the potential criticism of being ‘unscientific’. They stated that gut feelings were integral to efficient and professional patient care, particularly when the presentation causing concern fell into a grey-area of clinical practice that guidelines do not adequately address. As gut feelings were described as most reliable when used by an experienced GP, grounded on years of observations and accumulated clinical knowledge, there may be a role for mentoring less experienced GPs to understand and respond appropriately to them.

In this episode&nbsp;we talk to Drs Laura Swaithes and Andrew Finney from the Impact Accelerator Unit, School of Medicine, Keele University in the UK.Experience of implementing and delivering group consultations in UK general practice: a qualitative studyRead the paper: https://doi.org/10.3399/BJGP.2020.0856Group consultations are a relatively new approach in UK general practice, with much of the literature examining the impact on clinical outcomes. This study explores the experiences of general practice staff implementing and delivering group consultations. Recommendations for clinicians focus on the need for an implementation strategy that considers local contextual circumstances, and, local and national evaluation data measuring process outcomes, to support the set-up and sustainability of the approach.

In this episode we talk to Dr Emily Donovan, a NIHR GP academic fellow from the School of Primary Care, Population Sciences and Medical Education at the University of Southampton.Paper: Domestic abuse among female doctors: thematic analysis of qualitative interviews in the UKRead the paper: https://doi.org/10.3399/BJGP.2020.0795Previous qualitative research has focused on a doctor’s role in supporting victim-survivors of domestic abuse (DA) reinforcing the stereotype in which the doctor helps others experiencing DA rather than being a victim-survivor themselves. This study explored single doctor mothers’ lived experience of DA and identified several unique barriers to seeking help. Healthcare professionals need to be aware of these in order to better support patients who are medical doctors.

In this episode we talk to Clare MacRae, a GP at the Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics in Edinburgh.Main paper: Comorbidity in chronic kidney disease:a large cross-sectional study of prevalence in Scottish primary care and this is at: https://doi.org/10.3399/bjgp20X714125Additional paper discussed: Potentially inappropriate prescribing in people with chronic kidney disease: cross-sectional analysis of a large population cohort and this is at: https://doi.org/10.3399/BJGP.2020.0871Chronic kidney disease (CKD) is common and results in significant mortality and morbidity, and is known to be commonly associated with hypertension, diabetes, and cardiovascular disease. Despite research indicating that people with CKD and comorbidity, of any type, are at increased risk of adverse clinical outcomes, little is known about the prevalence of discordant physical and mental health conditions in people with CKD. The present study found that almost all people with CKD have coexisting comorbidities, and that extreme comorbidity is &gt;40 times more common in adults with CKD compared with age-, sex-, and deprivation-adjusted controls. The majority of discordant physical and mental health conditions were more common in people with CKD.

&nbsp;In this episode&nbsp;I am joined by two of our Associate Editors, Nada Khan and Tom Round, for some conversation. The February issue has just been published and we talk over some of the highlights in this month's issue.FEBRUARY ISSUE: https://bjgp.org/content/71/703EDITORIAL: COVID-19 vaccination programme: a central role for primary care https://doi.org/10.3399/bjgp21X714929EDITORIAL: Long COVID and the importance of the doctor–patient relationship https://doi.org/10.3399/bjgp21X714641EDITORIAL: Integrating primary care across the prison and community interface https://doi.org/10.3399/bjgp21X714653RESEARCH: Identifying patients at risk of psychosis: a qualitative study of GP views in South West England https://doi.org/10.3399/bjgp20X713969LIFE &amp; TIMES: The MRCGP Recorded Consultation Assessment: time to drop 10 minutes as standard? https://doi.org/10.3399/bjgp21X714725LIFE &amp; TIMES: The trolley problem, 2021 style https://doi.org/10.3399/bjgp21X714773Visit BJGP Life: www.bjgplife.com/contributeBook mentioned: On Immunity by Eula Bliss

In this episode we talk to Professor Jane Gunn, chair of primary care research, Department of General Practice, Melbourne Medical School, University of Melbourne, Australia.The paper is: Matching depression management to severity prognosis in primary care: results of the Target-D randomised controlled trialRead the paper:&nbsp;https://doi.org/10.3399/BJGP.2020.0783 Depression is a leading contributor to the global burden of disease and a significant problem in primary care, where it is typically identified and managed. Stepped care approaches are recommended but difficult to implement in routine care, due in part to a lack of effective tools to guide GPs in matching intervention intensity to patient need. Therefore, a clinical prediction tool was developed, which was embedded into a person-centred e-health platform, that matches depression management options to symptom severity prognosis. This randomised controlled trial showed using this platform results in greater improvement in depressive symptoms at 3 months compared to usual care. This approach could be implemented in routine care to support more efficient and effective depression care without adding to GPs’ workload.

In this episode we talk to Dr Garth Funston, a Clinical Research Fellow, from the Primary Care Unit, Department of Public Health and Primary Care at the University of Cambridge. The paper is: Time from presentation to pre-diagnostic chest X-ray in patients with symptomatic lung cancer: a cohort study using electronic patient records from English primary care.Read the paper:&nbsp;https://doi.org/10.3399/bjgp20X714077England’s national cancer referral guidelines recommend that patients attending general practice with unexplained symptoms possibly caused by lung cancer, such as persistent cough, shortness of breath, and weight loss, have a chest X-ray promptly (within 14 days) to aid timely diagnosis. Only 35% of patients with lung cancer in this study had a chest X-ray within the recommended 14 days; and time between attending general practice with symptoms and having an X-ray was longer among people who smoke, females, and older patients. This research highlights a potential source of delayed lung cancer diagnosis and could inform initiatives aiming to achieve earlier diagnosis and improve outcomes.

In this episode we talk to Daniela Strelchuk from Population Health Sciences at the University of Bristol and Professor Stan Zammit from the Centre for Academic Mental Health, also at Bristol. The paper is: Identifying patients at risk of psychosis: a qualitative study of GP views in South West EnglandRead the paper:&nbsp;https://doi.org/10.3399/bjgp20X713969Previous research has shown that GPs have limited knowledge about the insidious symptoms of psychosis but little is known about the difficulties that GPs face in identifying patients at risk of psychosis. This study used semi-structured interviews to explore GPs’ experiences of this patient group, and found that some GPs were not familiar with the concept of being at risk of developing psychosis. Whereas this could, in itself, be a barrier to identifying these patients, other barriers were present that related to patients not consulting or disclosing psychotic symptoms, lack of continuity of care, and high thresholds for accessing secondary care services.

In this episode we talk to Dr Gilly Mroz who is a postdoctoral researcher at the University of Oxford and Professor Trish Greenhalgh from the Nuffield Department of Primary Care Health Sciences at Oxford as well. The title of the paper is: Changing media depictions of remote consulting in COVID-19: analysis of UK newspapersRead the paper: https://doi.org/10.3399/BJGP.2020.0967Remote consulting changed UK general practice overnight, resulting in new barriers to access and levels of care. This study explored how this change was portrayed in national newspapers over time. Early newspaper coverage of this change was largely positive and emphasised its necessity for safety reasons during the pandemic. Later coverage was more negative, raising concerns about quality and safety of care and digital inequalities.

In this episode we talk to Dr Tom Margham who is a GP and Clinical Director at EQUIP (Enabling Quality Improvement in Practice) at Tower Hamlets Clinical Commissioning Group. The title paper is: Reducing missed appointments in general practice: evaluation of a quality improvement programme in east London.Read the paper: https://doi.org/10.3399/bjgp20X713909Missed appointments (DNAs) in general practice reduce clinical capacity and waste money. Most research on reducing DNAs focus on changing patient behaviour to optimise the existing appointment system.This study shows the impact of quality improvement coaching, including sharing appointment system data, among practices in one CCG. A case study illustrates how structural change to the appointment system can produce sustained reductions in DNA rates.

In this episode we talk to Dr Sarah Bailey who is a senior research fellow with the DISCO Cancer Diagnostics Group at the University of Exeter in the UK.The title of the paper is: Association of non-malignant diseases with thrombocytosis: a prospective cohort study in general practiceRead the paper: https://doi.org/10.3399/bjgp20X713501Thrombocytosis has recently emerged as a risk marker of undiagnosed cancer in patients in primary care. However, 89% of patients with thrombocytosis do not have undiagnosed cancer. This study estimates the link between thrombocytosis and non-malignant diseases. Primary care clinicians can use the results of this study as a clinical aid to look for and to diagnose associated diseases other than cancer in patients with thrombocytosis.

In this episode we talk to Dr Professor Alastair Hay from the Centre for Academic Primary Care, NIHR School for Primary Care Research, Bristol Medical School at the University of Bristol in the UK. Editorial: Point-of-care testing for respiratory infections during and after COVID-19 by Hannah V Thornton, Tanzeela Khalid and Alastair D HayRead the editorial: https://doi.org/10.3399/bjgp20X713561Alastair is an academic GP with a long interest in management of acute infections and the use of antibiotics in primary care and he leads a research group down in Bristol. He talks about attitudes and understanding of COVID testing; point-of-care testing; recent research on multiviral testing; and the use of CRP and how it fits into clinical care. He also tells us the research he would like to do in the future to help move this area of clinical practice forward.

In this episode I am talking to Dr Emma Sowden about heart failure with preserved ejection fraction. Emma is a research associate at the NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester.The title of the paper is: Understanding the management of heart failure with preserved ejection fraction: a qualitative multiperspective studyRead the paper: https://doi.org/10.3399/bjgp20X713477The type of heart failure called heart failure with preserved ejection fraction (HFpEF) is more common in older people with multiple long-term conditions. Although it is increasing in prevalence, it lacks evidence-based treatments. Research is needed to understand how to improve the management of patients with the condition. This study aimed to develop a detailed understanding of the perspectives of patients (including some relatives/carers), as well as primary and secondary care clinicians to inform the development of an improved model of care. The study found there were difficulties surrounding the timely identification of HFpEF and a widespread lack of understanding and awareness of the condition, which had the potential to influence approaches to management. There is a need to raise public and clinical awareness of HFpEF and develop a clear set of accepted practices concerning its management.

In this episode I am talking to Dr Bethany Bareham who is a research associate at the Population Health Sciences Institute at Newcastle University and she is funded by the School of Primary Care Research postdoctoral launching fellowship. The title of her paper is: Managing older people’s perceptions of alcohol-related risk: a qualitative exploration in Northern English primary careRead the paper: https://doi.org/10.3399/bjgp20X713405Different types of information and experiences affect older people’s perceptions of alcohol's effects and their decisions for alcohol use. This study suggests that older people may struggle to recognise risks associated with drinking, unless ill health or screening results indicate that they may be experiencing alcohol-related harm. Older people's perceptions that their drinking is ‘sensible’, or where their health has become difficult for them to manage, are challenges to be navigated in supporting healthier decisions. Primary care practitioners can help older people to recognise individual risks and the potential benefits of making healthier drinking decisions to maintain their quality of life.

We talk to Dr Daniel Stow about research into end-of-life recognition in older people. Daniel is a Research Associate at the Population and Health Sciences Institute, Newcastle University. He is funded by the School of Primary Care Research postdoctoral launching fellowship.Research title: Timing of GP end-of-life recognition in people aged ≥75 years: retrospective cohort study using data from primary healthcare records in EnglandRead the paper: https://doi.org/10.3399/bjgp20X713417Identification of end of life can be challenging for clinicians, particularly in older people living with frailty. In this study, fewer than half of people aged ≥75 years who died had a code in their electronic health record (EHR) to suggest that their death was anticipated by their GP. End-of-life codes in EHRs were entered near to death (median 4 months prior). In the minority of older decedents (aged ≥75 years) for whom end of life was recognised, only a small proportion were on the palliative care register or had their preferences for place of care or death recorded.

Dr Sian Russell talks about research into the use of NEWS in care homes. Sian Russell is a postdoctoral research associate at the Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne.Research title: Implementation of the National Early Warning Score in UK care homes: a qualitative evaluationRead the paper: https://doi.org/10.3399/bjgp20X713069Despite limited evidence for its feasibility and practicality, the National Early Warning Score (NEWS) is being implemented in community settings, such as care homes, and primary care. This evaluation of an implementation of NEWS in care homes in northern England adds to the growing debate on the use of NEWS in non-acute settings. Findings indicate that the implementation of NEWS in complex community settings, such as care homes, requires diligent and thoughtful planning. Communication with care home staff and health professionals, such as community nurses and GPs, should be ongoing during intervention development and implementation.

In this episode we talk to Professor Simon de Lusignan. He is Professor of Primary Care and Clinical Informatics at the Nuffield Department of Primary Health Care Sciences at the University of Oxford. Simon is Director of the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC). This is one of Europe's oldest sentinel systems. RCGP RSC has produced a weekly report of influenza, respiratory and other infections in primary care for over 50 years. RCGP RSC works closely with Public Health England (PHE) to report vaccine effectiveness.Title: Excess mortality in the first COVID pandemic peak: cross-sectional analyses of the impact of age, sex, ethnicity, household size, and long-term conditions in people of known SARS-Cov-2 status in EnglandRead the paper: https://doi.org/10.3399/bjgp20X713393The UK had one of the highest SARS-CoV-2 associated mortality rates, with &gt;42,000 deaths during the first wave of infection. Concerns about excess mortality still exist in care homes and widening social inequality has been suggested as a possible associated factor. Published reports showing disparities in SARS- CoV-2 infection and its impact on ethnic and socioeconomic variables have not included data on household size or clinical risks. Results from this observational cohort study showed living in households of ≥9 occupants was associated with a fivefold increase in relative mortality in the general population. Among people with known SARS-CoV-2 status (clinical or virological diagnosis), male sex, population density, black ethnicity (compared to white), and people with long-term conditions or learning disabilities had a higher odds of mortality. These findings reinforce the importance of the need for risk reduction strategies to reduce ethnic disparities, the impact of large household size, and increased risk associated with long-term conditions and learning disability.

In this episode Dr Elizabeth Lovegrove talks about research into ACE inhibitors and ARBs and the risk they pose in pregnancy.Pregnancy protection and pregnancies in women prescribed ACE inhibitors or ARBs: a cross-sectional study in primary careRead the paper: https://doi.org/10.3399/bjgp20X712997Exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers during pregnancy is associated with teratogenic risk to the fetus. This study shows that the recording of pre-pregnancy advice and contraception in women of childbearing age, who are prescribed such medicines, is suboptimal and a number of pregnancies occur in this population. As this may place women and their babies at risk of exposure to teratogens, there is a need for significant improvements in the care of these patients.

In this episode Dr Carol Sinnott talks about research into operational failures in primary care. She is a GP and a senior clinical research associate at the THIS Institute, University of Cambridge.Operational failures and how they influence the work of GPs: A qualitative study in primary careRead the paper: https://doi.org/10.3399/bjgp20X713009Operational failures, defined as inadequacies or errors in the information, supplies, or equipment needed for patient care, are known to be highly consequential in hospital environments. This qualitative study shows that operational failures are also common and burdensome in UK primary care. Examples included problems in the supply of information to GPs from external healthcare providers, technology problems, and missing or broken equipment. These problems required what was termed ‘compensatory labour’ to address them. Although GPs’ compensatory labour usually resolved the problem more quickly in the short term than did redirecting failures to their source, it may in fact be counterproductive in the longer term by rendering invisible at system level the operational failures themselves and the possible improvement opportunities associated with them.

In this episode Professor Tammy Hoffmann talks about research into the natural history of uncomplicated urinary tract infections that could have a big impact on conversations with women and treatment with antibiotics. She is a professor of Clinical Epidemiology and leads the Centre for Evidence-Informed Health Decisions in the Institute of Evidence-Based Healthcare, Bond University.Natural history of uncomplicated urinary tract infection without antibiotics: a systematic reviewRead the paper: https://doi.org/10.3399/bjgp20X712781Uncomplicated urinary tract infections (UTIs) are a very common reason for general practice consultations and one of the most common reasons for the prescription of antibiotics. Informed decision making should consider the benefit/harm trade-off of antibiotic use and the natural course of the illness. The studies reviewed in this paper, which focused solely on women, demonstrated that UTI symptoms resolve spontaneously in approximately a third of women in the first 7–10 days. Current guideline recommendations from the National Institute for Health and Care Excellence are to delay prescribing by two days but the findings of this systematic review indicate that this may be too short a timeframe.

In this episode, we talk about research that explores the perspectives of GPs and considers how we can help women and girls who are at risk or have experienced female genital mutilation (FGM). Dr Sharon Dixon is a GP and researcher at the Nuffield Department of Primary Care Health Sciences, University of Oxford.Supporting patients with female genital mutilation in primary care: a qualitative study exploring the perspectives of GPs' working in EnglandRead the paper: https://doi.org/10.3399/bjgp20X712637There are an estimated 137,000 women and girls born in countries where FGM is traditionally practised who are permanently resident in England and Wales in 2011. Though there was a significantly higher prevalence in urban areas, it was estimated that there would be no local authority areas without any women affected by FGM. The authors are unaware of any previous work considering GPs’ perspectives on supporting women with female genital mutilation (FGM) in primary care, including the impacts of recent English policy which includes a mandatory reporting policy and FGM Enhanced Dataset. GPs described tensions between their caring role and the policy requirements placed on them. The provision of specialist support, and holistic education could support GPs when caring for those from communities affected by FGM.

In this episode we talk to Professor Samuel Wong about his research into COVID-19 and its impact on loneliness and mental health in a cohort of older adults in Hong Kong. Professor Wong is a clinician with training in both Family Medicine and Public Health. He is the Director of the School of Public Health and Primary Care at the Chinese University of Hong Kong.Impact of COVID-19 on loneliness, mental health, and health service utilisation: a prospective cohort study of older adults with multimorbidity in primary careRead the full paper at: https://doi.org/10.3399/bjgp20X713021Although evidence suggests that social distancing measures are effective in controlling the spread of the novel coronavirus, there are likely to be adverse effects on psychological, social, and physical health, among one vulnerable population in particular — older adults with multimorbidity.Using pre- and peri- COVID-19 data from a cohort of older patients (≥60 years) with multimorbidity in primary care, this study aimed to understand changes in loneliness, mental health problems, and attendance to scheduled medical care among the cohort.It was found that older patients with multiple chronic conditions had increased loneliness, anxiety, and insomnia. They also had increased missed scheduled appointments for chronic disease care. Being female, living alone, and having more than four chronic conditions were risk factors. Interventions such as teleconsultations are needed for loneliness, mental health, and health service accessibility.The article highlights the importance of continuity of care in general practice, particularly for patients with multimorbidity conditions. The missed appointments observed in the current study can potentially lead to serious complications or adverse events if not addressed, as well as creating additional burden on the already stretched healthcare system considering the current climate of COVID-19. Future research attention is needed to provide alternative strategies for people with multiple chronic conditions.