BJGP Interviews

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