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‘We’re all doing different things’: Qualitative study exploring primary care practitioners’ perspectives of managing distress

Background: Distinguishing emotional distress from mental health problems such as anxiety and depression can be difficult for clinicians. Both commonly present and are managed in primary care. There are likely important differences in the management of emotional distress compared with depression/anxiety, but the current nature of assessment and management is unclear. Aim: Our aim was to explore how emotional distress is understood and how people are managed by a range of practitioners in primary care settings in the UK. Design and Setting: We conducted a qualitative study using semi-structured interviews with primary care practitioners in the UK. Method: Online interviews were conducted with practitioners who directly assess patients with mental health symptoms, including General Practitioners (GPs), Nurse Practitioners, Social Prescribers, and Mental Health Practitioners. Recruitment was via a digital poster circulated by Research Delivery Networks. Interviews covered how practitioners understood and identified distress, support provided to patients, and challenges to assessing and managing emotional distress. Verbatim transcriptions were analysed using an inductive thematic approach. Results: Twenty-nine interviews were conducted and four themes developed in collaboration with the wider team, including public contributors: ‘The multifaceted nature of distress’, ‘We’re all doing very different things’, ‘Managing and understanding distress is challenging’, and ‘De-medicalising distress in the face of increasing societal pressures’. Complexity was driven by the wide-ranging professionals involved, complex patient circumstances, systemic challenges, and societal contexts. Conclusion: Identifying and managing emotional distress is complex, variable and challenging. Complexity appears to be increasing through the systemic challenges and range of professionals involved.

Association of strong opioids and antibiotics prescribing with GP burnout: a retrospective cross-sectional study

Abstract Background Prescribing of strong opioids and antibiotics impacts patient safety, yet little is known about the effects GP wellness has on overprescribing of both medications in primary care. Aim To examine associations between strong opioid and antibiotic prescribing and practice- weighted GP burnout and wellness. Design and setting A retrospective cross-sectional study was undertaken using prescription data on strong opioids and antibiotics from the Oxford- Royal College of General Practitioners Research and Surveillance Centre linking to a GP wellbeing survey overlaying the same 4-month period from December 2019 to April 2020. Method Patients prescribed strong opioids and antibiotics were the outcomes of interest. Results Data for 40 227 patients (13 483 strong opioids and 26 744 antibiotics) were linked to 57 practices and 351 GPs. Greater strong opioid prescribing was associated with increased emotional exhaustion (incidence risk ratio [IRR] 1.19, 95% confidence interval [CI] = 1.10 to 1.24), depersonalisation (IRR 1.10, 95% CI = 1.01 to 1.16), job dissatisfaction (IRR 1.25, 95% CI = 1.19 to 1.32), diagnostic uncertainty (IRR 1.12, 95% CI = 1.08 to 1.19), and turnover intention (IRR 1.32, 95% CI = 1.27 to 1.37) in GPs. Greater antibiotic prescribing was associated with increased emotional exhaustion (IRR 1.19, 95% CI = 1.05 to 1.37), depersonalisation (IRR 1.24, 95% CI = 1.08 to 1.49), job dissatisfaction (IRR 1.11, 95% CI = 1.04 to 1.19), sickness–presenteeism (IRR 1.18, 95% CI = 1.11 to 1.25), and turnover intention (IRR 1.38, 95% CI = 1.31 to 1.45) in GPs. Increased strong opioid and antibiotic prescribing was also found in GPs working longer hours (IRR 3.95, 95% CI = 3.39 to 4.61; IRR 5.02, 95% CI = 4.07 to 6.19, respectively) and in practices in the north of England (1.96, 95% CI = 1.61 to 2.33; 1.56, 95% CI = 1.12 to 3.70, respectively). Conclusion This study found higher rates of prescribing of strong opioids and antibiotics in practices with GPs with more burnout symptoms, greater job dissatisfaction, and turnover intentions; working longer hours; and in practices in the north of England serving more deprived populations.

Providing inclusive care and empowering people with dementia as a clinical pharmacist: a qualitative study of clinical pharmacist’s experiences

Abstract Objectives Dementia is a growing global health concern, significantly impacting primary care settings, where the majority of care for people with dementia is provided. Underserved and vulnerable groups, who often face disparities in access to care are at greater risk of this strain. Clinical pharmacists are well-positioned to provide care but their potential contribution to enhancing person-centred and inclusive care for people with dementia is largely unexplored. The aims are to explore the views and experiences of primary care based clinical pharmacists in providing inclusive care to people with dementia in the community. Method We conducted 13 semi-structured interviews with primary care clinical pharmacists in England in 2023–2024, which were analysed using reflexive thematic analysis. Results Two overarching themes were developed from the interviews: 1) involving patients in decision-making, ensuring person-centered care and 2) the prevalence of health inequalities and the impact on patient care. Conclusion Taking a personalised and person-centred approach clinical pharmacists can engage with patients and carers in decision-making. This can empower people, particularly those from minoritised or disadvantaged groups, to take an active role in their care. This may help with medication adherence but also build trust, potentially leading to better quality and more equitable care. Personalised care should consider cultural beliefs and preferences to reduce misunderstandings or stigma and improve the overall experience for individuals, helping to reduce disparities.

Trends in full-time working in general practice: a repeated cross-sectional study

Background There is little evidence and no agreement on what constitutes full-time working for GPs. This is essential for workforce planning, resource allocation, and accurately describing GP activity. Aim To clarify the definition of full-time working for GPs, how this has changed over time, and whether these changes are explained by GP demographics. Design and setting Data were obtained from repeated cross-sectional national surveys for GPs, which were conducted between 2010 and 2021. Method A comparison was undertaken of three measures of working time commitments (hours and sessions per week and hours per session) plus a measure of workload intensity across survey years. Multiple regression was used to adjust the changes over time for age, sex, ethnicity, contract type, area deprivation, and rurality. Unadjusted hours and sessions per week were compared with definitions of full-time working. Results Average hours and sessions per week reduced from 40.5 (95% confidence interval [CI] = 38.5 to 42.5) to 38.0 (95% CI = 36.3 to 39.6) and 7.3 (95% CI = 7.2 to 7.3) to 6.2 (95% CI = 6.2 to 6.3) between 2010 and 2021, respectively. In 2021, 54.6% of GPs worked at least 37.5 hours per week and 9.5% worked at least nine sessions. Hours per session increased from 5.7 (95% CI = 5.7 to 5.7) to 6.2 (95% CI = 6.2 to 6.3) between 2010 and 2021. Partners worked more hours, sessions, and hours per session. Adjustments expanded the increase in hours per session from 0.54 to 0.61. Conclusion At the current average duration of sessions, six sessions per week aligns with the NHS definition of full-time hours. However, hours per week is a more consistent way to define full-time work for GPs.

Exploring patient and professional perspectives on implementing pharmacogenomic testing in the UK primary care setting and estimating the cost-effectiveness: a mixed-methods study protocol

Abstract Introduction Pharmacogenomic testing could potentially reduce the number of adverse drug reactions and improve treatment outcomes through tailoring treatment to an individual’s genetic makeup. Despite its benefits and the ambitions to integrate into routine care, the implementation of pharmacogenomic testing in primary care settings remains limited. This study aims to qualitatively explore the views of healthcare professionals (HCPs) and patients on implementing pharmacogenomic testing in the UK National Health Service (NHS) primary care setting and to estimate the cost-effectiveness of service-delivery implementation by comparing different HCPs’ models of care. Method This study consists of three workstreams (WS). WS1 is semi-structured interviews with General Practitioners, pharmacists, nurses and patients (24 participants) to explore implementation issues, including the perceived barriers and facilitators to delivering a pharmacogenomic service. WS2 consists of focus groups (between 24–36 participants) with genomic experts to develop practical pharmacogenomic-guided clinical pathways for primary care. WS3 will estimate the cost-effectiveness of implementing pharmacogenomic testing when led by different HCPs incorporating parameters from the literature, expert opinions, as well as data from WS1 and WS2. Analysis Thematic analysis will be used to analyse the qualitative data from WS1 and WS2, mapping findings onto the Consolidated Framework for Implementation Research domains, which will also be used as the theoretical framework. WS3 will be a decision-analytic model developed in Microsoft Excel to compare the cost-effectiveness of pharmacist-led, GP-led, nurse-led or multidisciplinary pathways.

Risk factors for pancreatic cancer in electronic health records: an umbrella review of systematic reviews and meta-analyses

Background Pancreatic cancer has poor survival because of predominantly advanced-stage diagnosis. One strategy for improving outcomes is earlier identification, possibly achievable by enhanced surveillance or improved risk prediction modelling. This umbrella review updates previous evidence with a comprehensive assessment of factors which could inform risk assessments. Methods Database searches were performed in MEDLINE and EMBASE via Ovid and the Science Citation Index Expanded of the Web of Science Core collection from inception to March 2025. Systematic reviews and meta-analyses of factors associated with altered risk of pancreatic cancer, available in a coded electronic healthcare record, were included. Participants in component studies were adults, and we compared exposed/not exposed/differentially exposed participants. There was no geographical restriction. The main outcome was potential risk factors for pancreatic cancer, categorised by degree of association. The study was registered with PROSPERO, registration number CRD42024526338. Findings 2386 abstracts and 449 full texts were dual screened, resulting in 168 studies included in the review, comprising 365 meta-analyses of individual risk factors or strata and >2,255,495 pancreatic cancer cases. 21 meta-analyses reported gender-disaggregated data which were extracted and reported separately. Of the 80 potential risk factors identified, 38 were associated with an increased pancreatic cancer risk, 11 with a protective effect, and 31 had no significant association with pancreatic cancer. Major newly found risk factors were autoimmune liver disease, BRCA gene mutation, co-infection with hepatitis B and C, and insulin use. Interpretation This comprehensive umbrella review of pancreatic cancer risk factors provides an up-to-date summary useful for identifying prevention and surveillance approaches, and for developing risk prediction models and directing future research.

A heterogeneity analysis of health-related quality of life in early adults born very preterm or very low birthweight across the sociodemographic spectrum

Abstract Preterm birth and very low birthweight (VP/VLBW) are associated with poorer health-related quality of life (HRQoL) outcomes extending into adulthood, yet it remains unclear how these effects differ across sociodemographic subgroups. This study aimed to identify heterogeneity in the association of VP/VLBW on HRQoL in early adulthood, specifically examining maternal age, education, and ethnicity. Individual-level data from three longitudinal cohorts within the Research on European Children and Adults Born Preterm Consortium were analysed, including adults born VP (< 32 weeks’ gestation) or VLBW (< 1500g), compared to term-born or normal birthweight controls. HRQoL was assessed using the Health Utilities Index Mark 3 (HUI3) at mean ages of 18–26 years. Bayesian Causal Forest and Shrinkage Bayesian Causal Forest methodologies were employed to estimate conditional average treatment effects. Results indicated significant heterogeneity in the effects of VP/VLBW birth on HRQoL by maternal age and education. Individuals born to mothers aged ≤25 years experienced the largest decrement in HUI3 scores (−0.08; 95 % CI −0.13, −0.02), compared to minimal or no decrements for individuals born to mothers aged ≥26 years. Similarly, lower maternal education was associated with larger decrements (−0.05; 95 % CI −0.09, −0.01), whereas high maternal education showed negligible impact (0.01; 95 % CI −0.04, 0.06). These findings highlight maternal sociodemographic characteristics as critical modifiers of VP/VLBW impacts on adult HRQoL, emphasizing the need for targeted health interventions for disadvantaged groups. Future research is warranted to examine whether modern neonatal care and changes in socioeconomic conditions can mitigate these HRQoL disparities across the life course.

Practitioners’ views on the measurement and management of postural hypotension in general practice: a qualitative inquiry

Background: Postural hypotension (PH) is associated with cognitive decline, falls and allcause mortality, representing a substantial burden on the NHS. PH is often asymptomatic, making detection and treatment difficult. Currently, there is no systematic approach to measuring and managing PH in UK general practice. Aim: To explore barriers and facilitators to improving PH measurement and management. Design and Setting: Qualitative interview study with healthcare practitioners in general practices in England. Methods: We conducted individual, remote, semi-structured interviews with a range of healthcare practitioners (HCPs) who measure blood pressure (BP) in general practice, to explore their views and experiences of measuring and managing PH. Participants were identified from expressions of interest during a national survey. Interviews were video and audio-recorded, transcribed verbatim and analysed thematically. Results: 26 HCPs in 24 practices across nine Clinical Research Networks in England were interviewed between March and July 2023. HCPs checked for PH when patients were older, reported dizziness, fatigue or had chronic conditions. Despite awareness of clinical guidelines, various diagnostic definitions were provided and measurement protocols varied between participants. Sit-to-stand rather than supine-to-stand measurements were considered more feasible due to time constraints and patient mobility. Education and training, as well as incentives and specialist clinics, were suggested as methods to improve PH measurement and management. Conclusions: This is the first study to explore barriers to, and facilitators of, PH measurement in English general practice. Findings suggest a more systematic approach to measurement is needed to improve detection and management of PH in general practice.

Identifying novel biomarkers suitable for early detection of Intrathoracic cancers in primary care: a systematic review.

Review objectives Are there any novel biomarkers for detection and diagnosis of intrathoracic cancers that are suitable for use in primary care? To address this review question, we will identify and describe existing validated biomarkers for the detection/diagnosis of intrathoracic (primary lung/bronchus/trachea, mesothelioma, and thymoma) cancers, focusing on their: • Diagnostic performance across different population groups (such as setting, symptomatology, health behaviors, or other patient characteristics) • Classification based on sample source (such as blood, saliva, breath, or sputum) and molecular function (such as proteins, volatile organic compounds, microRNAs, and others) • Potential relevance to populations such as primary care where cancer prevalence is low compared to specialist settings.

Inter-arm blood pressure difference and cardiovascular risk estimation in primary care: a pilot study

Abstract Background Systolic inter-arm differences (IAD) in blood pressure (BP) contribute independently to cardiovascular risk estimates. This can be used to refine predicted risk and guide personalised interventions. Aim To model the effect of accounting for IAD in cardiovascular risk estimation in a primary care population free of pre-existing cardiovascular disease. Design & setting A cross-sectional analysis of people aged 40–75 years attending NHS Health Checks in one general practice in England. Method Simultaneous bilateral BP measurements were made during health checks. QRISK2, atherosclerotic cardiovascular disease (ASCVD), and Framingham cardiovascular risk scores were calculated before and after adjustment for IAD using previously published hazard ratios. Reclassification across guideline-recommended intervention thresholds was analysed. Results Data for 334 participants were analysed. Mean (standard deviation) QRISK2, ASCVD, and Framingham scores were 8.0 (6.9), 6.9 (6.5), and 10.7 (8.1), respectively, rising to 8.9 (7.7), 7.1 (6.7), and 11.2 (8.5) after adjustment for IAD. Thirteen (3.9%) participants were reclassified from below to above the 10% QRISK2 threshold, three (0.9%) for the ASCVD 10% threshold, and nine (2.7%) for the Framingham 15% threshold. Conclusion Knowledge of IAD can be used to refine cardiovascular risk estimates in primary care. By accounting for IAD, recommendations of interventions for primary prevention of cardiovascular disease can be personalised and treatment offered to those at greater than average risk. When assessing elevated clinic BP readings, both arms should be measured to allow fuller estimation of cardiovascular risk.

Blood test result communication in primary care: mixed-methods systematic review protocol

Abstract Background: After testing, ensuring test results are communicated and actioned is important for patient safety, with failure or delay in diagnosis the most common cause of malpractice claims in primary care worldwide. Identifying interventions to improve test communication from the decision to test through to sharing of results has important implications for patient safety, GP workload, and patient engagement. Aim: To assess the factors around communication of blood test results between primary care providers (for example GPs, nurses, reception staff) and their patients and carers. Design & setting: A mixed methods systematic review including primary studies involving communication of blood test results in primary care. Method: The review will use a segregated convergent synthesis method. Qualitative information will be synthesised using a meta-aggregative approach, and quantitative data will be meta-analysed or synthesised if pooling of studies is appropriate and data are available. If not, data will be presented in tabular and descriptive summary form. Conclusion: This review has the potential to provide conclusions about blood test result communication interventions and factors important to stakeholders, including barriers and facilitators to improved communication. Keywords: Blood tests; communication; hematological tests; patient satisfaction; patient-centred care.

Associations between burnout and career disengagement factors among general practitioners: a path analysis

Violence and Abuse towards General Practice Staff by Patients and the Public: A Scoping Review

Abstract Background General practice is the gatekeeper to secondary care in many countries. This unique role may expose general practice staff to violence and abuse by patients and the public, yet violence and abuse in secondary care receives more attention than that in general practice. Existing reviews on primary care do not distinguish the perpetrators of violence. A scoping review on violence and abuse by patients and the public towards general practice staff was conducted. Aim: to analyse the evidence on: 1. The extent, characteristics and impact of violence and abuse by patients or the public towards general practice staff. 2. Practices in violence and abuse prevention and support in general practice at individual and organisational levels. Design and Setting This scoping review followed the updated Joanna Briggs Institute guidelines and the PRISMA ScR guidelines. Method Six bibliographic databases, Google and Google Scholar were systematically searched. De-duplicated citations (N=19,519) were independently screened by two reviewers. Data were extracted with a bespoke extraction form. Results Fifty studies from 24 countries were included. Past-year rates for violence and abuse by patients and the public towards general practice staff ranged from 13.8% to 90.3% while career-long estimates were 18.3% to 91%. Long waiting times and unmet patient demands were the most common reasons. It impacted staff mental health and turnover intention and service capacity. No evaluated prevention or support interventions were reported. Conclusion Violence and abuse towards general practice staff is widespread, impacting both individuals and service delivery. However, interventions are under researched.

Arm Based on LEg blood pressures (ABLE-BP): can systolic ankle blood pressure measurements predict systolic arm blood pressure? An individual participant data meta-analysis from the INTERPRESS-IPD Collaboration

Abstract Objectives To determine associations between arm and ankle systolic blood pressures (SBPs), develop and validate a multivariable model predicting arm SBP from ankle SBP, and investigate associations between ankle SBP, cardiovascular disease and mortality. Design Ankle-arm SBP differences were examined in two-stage individual participant data (IPD) meta-analyses using multivariable hierarchical linear regression models. Models were used to derive and validate a prediction model for arm SBP based on ankle SBP. Model performance was assessed using area under the receiver operating characteristic (AUROC) curve analyses. Prognostic associations of ankle SBP with outcomes were examined using Cox proportional hazards models. Data sources Searches identified cohorts for the Inter-arm Blood Pressure Difference IPD (INTERPRESS-IPD) Collaboration from Medline, Old Medline, Medline in process, Embase and CINAHL databases from inception until January 2017; unpublished data were also sought. Required primary outcomes were all-cause mortality, cardiovascular mortality, and/or fatal and non-fatal cardiovascular events. Eligibility criteria Prospective studies from community, primary care or general clinic settings, without language restriction, that recorded SBP in both arms were eligible. Adults aged ≥18 years with SBP measured in all four limbs, in a supine position, were included in the current analyses. People with peripheral artery disease were excluded. Data extraction and synthesis Anonymised datasets were individually cleaned and then combined into a single dataset for the INTERPRESS-IPD Collaboration. Results The current dataset included 33 710 participants from 14 studies; mean age 58 years, 45% female, mean baseline arm blood pressure 138/80 (SD: 20/12) mm Hg. Mean ankle SBP was 12.0 mm Hg (95% CI 8.8 to 15.2) higher than arm SBP. The multivariable model predicting arm SBP from ankle SBP demonstrated excellent performance (AUROC curves, sensitivities and specificities were >0.82, 0.80 and 0.82, respectively, at all BP thresholds from 130 to 160 mm Hg). Model performance was superior to existing arithmetic formulae. Ankle SBP was neither associated with all-cause nor cardiovascular mortality (HR 1.000 (0.997 to 1.002; p=0.682) and 1.001 (0.996 to 1.005; p=0.840), respectively). However, lower-reading ankle SBP was associated with fatal or non-fatal cardiovascular events (HR 1.005 (1.002 to 1.007; p<0.001). Conclusions On average, ankle SBP is 12 mm Hg higher than arm SBP. Estimating individual arm SBP from ankle SBP measurements with a multivariable model is more accurate than existing fixed arithmetic formulae. This model, operationalised in an online calculator (https://ablebp.research.exeter.ac.uk/), could facilitate hypertension management and cardiovascular care for people unable to have arm SBP measured.

Identifying risks in dementia care: Insights from a qualitative study with clinical pharmacists

Introduction People with dementia experience complex healthcare needs. Clinical pharmacists play a crucial role in optimising medication management and ensuring patient safety within the primary care setting. However, little is known about the specific barriers and challenges they face when delivering dementia care. This study investigates the safety of dementia care in the community, focusing on the experiences of clinical pharmacists. Methods A qualitative study using semi-structured interviews with clinical pharmacists. Data analysis employed codebook thematic analysis, guided by the SEIPS 2.0 framework. Results Thirteen clinical pharmacists were interviewed. Key risks include variations in pharmacist expertise, communication barriers, limited resources, and systemic challenges. Using the SEIPS 2.0 framework, the complex interactions between work systems (people, tools, tasks, organisation and environment) and work processes were identified, which impact safety outcomes for both clinical pharmacists and people with dementia. Conclusions Interviews revealed a spectrum of risks associated with dementia care in primary care. This study highlights the complex interplay of factors influencing the safety of dementia care. A proactive, multifaceted approach addressing training, interprofessional collaboration, and system-level adaptations is crucial to mitigate these risks and enhance patient safety in dementia care.

The Views of Adult Weight Management Dietitians on Service Provision for People With Obesity and Severe Mental Illness and/or Learning Disability: A Qualitative Study

ABSTRACT Specialist adult weight management (AWM) services (tier 3) provide multidisciplinary support for people with obesity to manage their weight. Many people with severe mental illness (SMI)/learning disability also have obesity. This study explored the opinions of specialist AWM dietitians in the North-East and North Cumbria (NENC) region regarding their skills, knowledge, and services for supporting people with obesity and SMI/learning disability. Dietitians (n = 9) were purposively selected and interviewed using Microsoft Teams in July 2023. The data was thematically analysed. Dietetic pre-registration training on SMI/learning disability was inconsistent. Dietitians' confidence in supporting people with SMI/learning disability was wide-ranging. Six themes were identified: training, resources, service provision, networking & external influences, assessment and compassion & self-efficacy. Specialist AWM dietitians in the NENC region are compassionate and want to provide a quality service for people with obesity and SMI/learning disability. However, they sometimes feel they fail these service users through a lack of training and resources. Training, accessible resources, and collaboration with mental health dietitians may improve AWM dietitians' confidence and skills when supporting people with SMI/learning disability and may reduce stigma. The British Dietetic Association (BDA) may wish to ensure training on SMI and learning disability is available for all dietitians, along with resource sharing. Additionally, limited staffing and waiting lists may impact the provision of reasonable adjustments required for people with additional needs. Alternative pathways for people with obesity and additional requirements may be of benefit. More comprehensively completed referrals and additional funding may facilitate this.

Multiple long-term conditions, loneliness and social isolation: A scoping review of recent quantitative studies

Abstract Background Multiple long-term conditions (MLTC), loneliness and social isolation are common in older adults. Recent studies have explored the association of MLTC with loneliness and social isolation. This scoping review aimed to map this current evidence and identify gaps in the literature. Methods A scoping review was conducted following the PRISMA guidelines for scoping reviews. Ovid Medline, Embase, CINAHL, The Cochrane Library, PsycInfo, and Bielefeld Academic Search Engine were searched for studies published between January 2020-April 2023. Quantitative studies, published in any language, that assessed the association of MLTC with loneliness and/or social isolation were included. Results 1827 records were identified and screened. Of these, 17 met inclusion criteria. Most studies were cross-sectional and based on older adults. Studies were conducted in Europe, the US, Canada, and low- and middle-income countries. Ten studies focused on the association between MLTC and loneliness, six assessed the association between MLTC and social isolation and one examined associations with both loneliness and social isolation. Most studies reported a significant cross-sectional association of MLTC with loneliness, but there was weaker evidence for a longitudinal association between MLTC and loneliness and an association between MLTC and social isolation. Studies were heterogenous in terms of measures and definitions of loneliness/social isolation and MLTC, confounders adjusted for, and analytical models used, making comparisons difficult. Conclusions Further population-based longitudinal studies using consistent measures and methodological approaches are needed to improve understanding of the association of MLTC with both loneliness and social isolation.

Young people's priorities for the self-management of distress after stoma surgery due to inflammatory bowel disease: A consensus study using online nominal group technique

Abstract Introduction The aim of this study was to gain consensus among young people with a stoma due to inflammatory bowel disease (IBD) on the priorities for the content of an intervention for the self-management of stoma-related distress. The current identification and management of distress in young people with a stoma is often suboptimal in clinical settings and there is a need for improved support resources. Methods Two consensus group meetings were carried out via online video conferencing, using nominal group technique. Participants generated, rated on a Likert scale and discussed, topics for inclusion in a future self-management intervention. Results Nineteen young people, aged 19–33, with a stoma due to IBD took part in one of two group meetings. Participants were located across England, Scotland, and Northern Ireland. Twenty-nine topics were generated by participants, seven of which reached consensus of ≥80%, that is, a mean of ≥5.6 on a 7-point Likert scale. These were: receiving advice from young people with lived experience of stoma surgery; advice on/addressing concerns about romantic relationships, sex and intimacy; information about fertility and pregnancy related to stoma surgery; stoma ‘hacks’, for example, useful everyday tips regarding clothing, making bag changes easier and so forth; reflecting on and recognising own emotional response to surgery; tips on managing the stoma during the night; and processing trauma related to the illness and surgery journey. Conclusions Findings extend previous research on young people's experiences of stoma surgery, by generating consensus on young people's priorities for managing distress related to surgery and living with a stoma. These priorities include topics not previously reported in the literature, including the need for information about fertility and pregnancy. Findings will inform the development of a self-management resource for young people with an IBD stoma and have relevance for the clinical management of stoma-related distress in this population. Patient or Public Contribution Three patient contributors are co-authors on this paper, having contributed to the study design, interpretation of results and writing of the manuscript. The study's Patient and Public Involvement and Engagement advisory group also had an integral role in the study. They met with the research team for four 2-h virtual meetings, giving input on the aims and purpose of the study, recruitment methods, and interpretation of findings. The group also advised on the age range for participants. The views of young people with a stoma are the central component of the study reported in this paper, which aims to gain consensus among young people with an IBD stoma on their priorities for the content of a resource to self-manage distress related to stoma surgery.

Patterns and trends of medicinal poisoning substances: a population-based cohort study of injuries in 0–11 year old children from 1998–2018

Abstract Background There have been sharp increases in antidepressant and opioid prescriptions over the last 10 years, as well as increased over-the-counter medicine availability. However, the impact on childhood medicinal poisonings rates, particularly by socioeconomic deprivation is unclear. This study reports population level medicinal poisoning substance patterns in England among children aged 0–11 years, helping inform safety advice and poisoning prevention interventions. Methods An open cohort study of 1,489,620 0–11 year olds was conducted from 1998 to 2018, using the Clinical Practice Research Datalink, to examine inpatient hospital admissions for poisoning. Incidence rates and adjusted incidence rate ratios (aIRR) were calculated for poisoning substance groups by age, sex, socio-economic deprivation and year. Results 3,685 medicinal poisoning hospital admissions were identified. The most common substances were paracetamol (33.2%), dependence/withdrawal risk drugs (DWRD - antidepressants, opioids, gabapentinoids, benzodiazepines) (13.5%) and other over-the-counter (OTC) analgesics/anti-common cold drugs (13.0%). Over the study period DWRD poisonings decreased 33% (aIRR 0.67, 95%CI 0.50–0.90 comparing 2013/14-2017/18 to 1998/99-2002/03), while paracetamol poisonings increased 43% (aIRR 1.43, 95%CI 1.20–1.70 for the same periods), with no change in incidence rates for other OTC drugs (aIRR 0.82, 95% CI 0.60–1.12) or all medications combined (aIRR 0.97, 95%CI 0.88–1.07). A gradient in poisonings by area-level socioeconomic deprivation was shown for all medications (aIRR 1.32, 95%CI 1.18–1.47 for most deprived compared to least deprived quintile), and DWRDs (aIRR 2.03, 95%CI 1.42–2.88 for 4th most deprived quintile and aIRR 1.88, 95%CI 1.32–2.66 for 5th most deprived quintile, compared to least deprived quintile), but not for paracetamol or other OTC drug poisonings. Conclusions Poisonings from DWRDs decreased by 33%, while paracetamol poisonings increased by 43% during the study period. There was a gradient by area-level socioeconomic deprivation in prescribed medication poisonings, including drugs with withdrawal/dependence risk, but not OTC medication poisonings. Households in more socioeconomically deprived areas have the potential to benefit most from measures to improve safe storage of medicines and are likely to require targeted interventions providing education and safety equipment. In addition, universal promotion of the safe storage of OTC and prescribed medicines must be provided by prescribers, community pharmacies and other outlets of such medication.

The reflexive imperative in the digital age: Using Archer’s ‘fractured reflexivity’ to theorise widening inequities in UK general practice

Abstract ‘Reflexivity’, as used by Margaret Archer, means creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. People with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. The substantial widening of health inequities since the introduction of remote and digital modalities in health care has been well-documented but inadequately theorised. In this article, we use Archer’s theory of fractured reflexivity to understand digital disparities in data from a 28-month longitudinal ethnographic study of 12 UK general practices and a sample of in-depth clinical cases from ‘Deep End’ practices serving highly deprived populations. Through four composite patient cases crafted to illustrate different dimensions of disadvantage, we show how adverse past experiences and structural inequities intersect with patients’ reflexive capacity to self-advocate and act strategically. In some cases, staff were able to use creative workarounds to compensate for patients’ fractured reflexivity, but such actions were limited by workforce capacity and staff awareness. Unless a more systematic safety net is introduced and resourced, people with complex needs are likely to remain multiply disadvantaged by remote and digital health care.