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Background: Primary care in England is contracted to provide essential services. Many practices also provide additional services, termed 'directed enhanced services' (DES), for extra income. The optional nature of DES may result in inequitable service delivery. Aim: To determine the range of DES activity and equity of service provision. Design & setting: A cross-sectional analysis of data from general practices in England took place from 2018-2019. Method: DES were defined in terms of activity level and measured as total DES funding per registered patient. Linear regression modelling was used to explore the relationship between DES activity, practice, and population characteristics. Results: Data were available for 6873 practices providing up to 10 DES in the initial sample. Due to negative funding amounts and a list size of ≤750 registered patients, 24 practices were excluded. Of the final sample (n = 6849), highest DES provision was for influenza and pneumococcal immunisation (99.9%), pertussis immunisation (97.9%), rotavirus and shingles immunisation (99.9%), meningitis immunisation (99.7%), and childhood immunisation (99.6%); lowest provision was for extended hours access (72.4%), violent patient services (2.0%), and out-of-area urgent care (1.3%). Mean DES funding was £6.25 per patient. In deprived areas, DES funding was £0.35 lower (95% confidence interval [CI] = £0.60 to £0.10) per patient (most versus least deprived quintiles); ethnic group-related differences were not significant. DES funding was higher in practices with more GPs or practice nurses per patient. In deprived communities, there was less immunisation activity (including influenza, pneumococcal, meningitis, childhood, and rotavirus and shingles immunisation) and provision of extended hours access; however, learning disability checks provision was greater in these communities. Conclusion: DES provision is lower in deprived areas (notably for immunisations and some aspects of access) but higher in better staffed practices. Voluntary quality schemes may contribute to widening health inequalities. [ABSTRACT FROM AUTHOR]

Background: Providing high-quality clinical care and good patient experience are priorities for most healthcare systems.Aim: To understand the relationship between general practice funding and patient-reported experience.Design and Setting: Retrospective longitudinal study of English general practice-level data for the financial years 2013-2014 to 2016-2017.Method: Data for all general practices in England from the General and Personal Medical Services database were linked to patient experience data from the GP Patient Survey (GPPS). Panel data multivariate regression was used to estimate the impact of general practice funding (current or lagged 1 year) per patient on GPPS-reported patient experience of access, continuity of care, professionalism, and overall satisfaction. Confounding was controlled for by practice, demographic, and GPPS responder characteristics, and for year effects.Results: Inflation-adjusted mean total annual funding per patient was £133.66 (standard deviation [SD] = £39.46). In all models, higher funding was associated with better patient experience. In the model with lagged funding and practice fixed effects (model 6), a 1 SD increase in funding was associated with increases in scores in the domains of access (1.18%; 95% confidence interval [CI] = 0.89 to 1.47), continuity (0.86%; 95% CI = 0.19 to 1.52), professionalism of GP (0.47%; 95% CI = 0.22 to 0.71), professionalism of nurse (0.51%; 95% CI = 0.24 to 0.77), professionalism of receptionist (0.51%; 95% CI = 0.24 to 0.78), and in overall satisfaction (0.88%; 95% CI = 0.52 to 1.24).Conclusion: Better-funded general practices were more likely to have higher reported patient experience ratings across a wide range of domains. [ABSTRACT FROM AUTHOR]

Background: The first wave of the London COVID-19 epidemic peaked in April 2020. Attention initially focused on severe presentations, intensive care capacity, and the timely supply of equipment. While general practice has seen a rapid uptake of technology to allow for virtual consultations, little is known about the pattern of suspected COVID-19 presentations in primary care.Aim: To quantify the prevalence and time course of clinically suspected COVID-19 presenting to general practices, to report the risk of suspected COVID-19 by ethnic group, and to identify whether differences by ethnicity can be explained by clinical data in the GP record.Design and Setting: Cross-sectional study using anonymised data from the primary care records of approximately 1.2 million adults registered with 157 practices in four adjacent east London clinical commissioning groups. The study population includes 55% of people from ethnic minorities and is in the top decile of social deprivation in England.Method: Suspected COVID-19 cases were identified clinically and recorded using SNOMED codes. Explanatory variables included age, sex, self-reported ethnicity, and measures of social deprivation. Clinical factors included data on 16 long-term conditions, body mass index, and smoking status.Results: GPs recorded 8985 suspected COVID-19 cases between 10 February and 30 April 2020.Univariate analysis showed a two-fold increase in the odds of suspected COVID-19 for South Asian and black adults compared with white adults. In a fully adjusted analysis that included clinical factors, South Asian patients had nearly twice the odds of suspected infection (odds ratio [OR] = 1.93, 95% confidence interval [CI] = 1.83 to 2.04). The OR for black patients was 1.47 (95% CI = 1.38 to 1.57).Conclusion: Using data from GP records, black and South Asian ethnicity remain as predictors of suspected COVID-19, with levels of risk similar to hospital admission reports. Further understanding of these differences requires social and occupational data. [ABSTRACT FROM AUTHOR]

Objectives To test the hypothesis that prior antibiotics influences the risk of developing RA. Methods A case–control study was conducted over 15 years using the UK's Royal College of General Practitioners Research and Surveillance Centre database. The frequency and type of antibiotic prescription for patients who subsequently developed RA were compared with antibiotic prescriptions in a control group of patients who remained free of RA. Cases, defined as patients with a new diagnosis of RA made between 2006 and 2018, were matched with up to four RA-free controls on practice, age, gender and date of diagnosis. Exposure was measured by the number and type of prescriptions for antibiotics prior to the RA diagnosis or to the index date in controls. Results A total of 8482 patients with a new diagnosis of RA between 2006 and 2018 were compared with 22 661 controls. There was a higher likelihood of an RA diagnosis after antibiotic prescriptions within 1 year, 5 years and ever with a strong dose–response. Patients receiving >10 antibiotics in a 5 year period were more than twice as likely to receive an RA diagnosis as controls [adjusted odds ratio 2.65 (CI 2.40, 2.93)]. Conclusion Exposure to antibiotics prior to the diagnosis was a significant risk factor for RA. This could reflect an immunological response to a compromised microbiome. Alternatively, patients with pre-symptomatic or early undiagnosed RA may have been more likely to present to their general practitioner with infections due to an unrecognized effect of RA. [ABSTRACT FROM AUTHOR]

Introduction: Seventy-five percent of all antimicrobials are prescribed in primary care. There is a growing concern about inappropriate oral antimicrobial prescribing. Interventions to enhance antimicrobial stewardship are actively promoted through educational and other means. GP training practice status has been shown to influence patient care. This study seeks to study the influence of GP training practice status on antimicrobial prescribing. Methods: A cross-sectional analysis of practice antimicrobial prescribing data was conducted for the year 2015-2016 comparing training and non-training practices across England. Data for all practices and prescribing was obtained from NHS Digital. Univariate analyses were conducted on the two measures of antibiotic prescribing included in the study. Multivariable regression models were constructed to identify the predictors of antibiotic prescribing volumes and of broad spectrum antibiotic prescribing. Results: GP training practice status was a significant predictor of overall antibiotic prescribing volume, B = -0.009 (95% confidence intervals, -0.012, -0.005), p < 0.001. GP training practices prescribed fewer antibiotics, representing a reduction of 6.2 centiles from the median. GP training practice status was also a significant predictor of broad spectrum antibiotic prescribing, B = -0.3 (95% confidence intervals, -0.04, -0.01), p = 0.001. GP training practices prescribed fewer broad spectrum antibiotics, representing a reduction from the median of 6.0 centiles. Discussion: Training practices prescribe fewer antimicrobials overall and specifically fewer broad spectrum oral antimicrobials (quinolones and cephalosporins). There is a need for further research to understand the interplay between postgraduate GP training and reductions in antimicrobial prescribing. [ABSTRACT FROM AUTHOR]

Background: Population factors, including social deprivation and morbidity, predict the use of emergency departments (EDs).Aim: To link patient-level primary and secondary care data to determine whether the association between deprivation and ED attendance is explained by multimorbidity and other clinical factors in the GP record.Design and Setting: Retrospective cohort study based in East London.Method: Primary care demographic, consultation, diagnostic, and clinical data were linked with ED attendance data. GP Patient Survey (GPPS) access questions were linked to practices.Results: Adjusted multilevel analysis for adults showed a progressive rise in ED attendance with increasing numbers of long-term conditions (LTCs). Comparing two LTCs with no conditions, the odds ratio (OR) is 1.28 (95% confidence interval [CI] = 1.25 to 1.31); comparing four or more conditions with no conditions, the OR is 2.55 (95% CI = 2.44 to 2.66). Increasing annual GP consultations predicted ED attendance: comparing zero with more than two consultations, the OR is 2.44 (95% CI = 2.40 to 2.48). Smoking (OR 1.30, 95% CI = 1.28 to 1.32), being housebound (OR 2.01, 95% CI = 1.86 to 2.18), and age also predicted attendance. Patient-reported access scores from the GPPS were not a significant predictor. For children, younger age, male sex, white ethnicity, and higher GP consultation rates predicted attendance.Conclusion: Using patient-level data rather than practice-level data, the authors demonstrate that the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use. [ABSTRACT FROM AUTHOR]

Postgraduate general practitioner (GP) training structures have been reorganised with the formation of Health Education England (HEE). We aimed to broaden the findings of previous studies and identify key features of GP training practices. In particular, we wanted to extend previous findings regarding QOF achievement and patient experience derived from the General Practice Patient Survey (GPPS), with recent data on the use of urgent cancer referral pathways (‘Two Week Wait’, or ‘2WW,’ referrals) and secondary care utilisation by GP training Practices. We compared training and non-training practices, adjusting for differences in practicesizeand demographic features. Compared with non-training practices, we found reported patient satisfaction with ‘access’ was 2.0% higher (p < 0.001), ‘communication’ 0.75% higher (p < 0.001), ‘overall experience’ 2.8% higher (p < 0.001), ‘continuity of care’ 2.2% lower (p < 0.001). Mean QOF scores were 11 points higher in training practices (p < 0.001). There were few differences between the two types of practice in terms of Emergency hospital admissions, Ambulatory Care Sensitive (ACSC) admissions, Accident and Emergency attendances and Out-Patient attendances. Training practices used the 2WW referral pathway more frequently than non-training practices resulting in a 1.1% higher ‘cancer detection rate’ (p = 0.007). [ABSTRACT FROM AUTHOR]

Background: The burden of morbidity represented by patients with long term conditions (LTCs) varies substantially between general practices. This study aimed to determine the characteristics of general practices with high morbidity burden. Method: Retrospective cross-sectional study; general practices in England, 2014/15. Three composite morbidity measures (MMs) were constructed to quantify LTC morbidity at practice level: a count of LTCs derived from the 20 LTCs included in the UK Quality and Outcomes Framework (QOF) disease registers, expressed as 'number of QOF LTCs per 100 registered patients'; the % of patients with one or more QOF LTCs; the % of patients with one or more of 15 broadly defined LTCs included in the GP Patient Survey (GPPS). Determinants of MM scores were analysed using multi-level regression models. Analysis was based on a national dataset of English general practices (n = 7779 practices); GPPS responses (n = 903,357); general practice characteristics (e.g. list size, list size per full time GP); patient demographic characteristics (age, deprivation status); secondary care utilisation (out-patient, emergency department, emergency admission rates). Results: Mean MM scores (95% CIs) were: 57.7 (±22.3) QOF LTCs per 100 registered patients; 22.8% (±8.2) patients with a QOF LTC; 63.5% (±11.7) patients with a GPPS LTC. The proportion of elderly patients and social deprivation scores were the strongest predictors of each MM score; scores were largely independent of practice characteristics. MM scores were positive predictors of secondary care utilization and negative predictors' access, continuity of care and overall satisfaction. Conclusions: Wide variation in LTC morbidity burden was observed across English general practice. Variation was determined by demographic factors rather than practice characteristics. Higher rates of secondary care utilisation in practices with higher morbidity burden have implications for resource allocation and commissioning budgets; lower reported satisfaction in these practices suggests that practices may struggle with increased workload. There is a need for a readily available metric to define the burden of morbidity and multimorbidity in general practice. [ABSTRACT FROM AUTHOR]

Background: Diabetes affects around 3.6 million people in the UK. Previous research found that general practices employing more nurses delivered better diabetes care, but did not include data on individual patient characteristics or consultations received. Aim: To examine whether the proportion of consultations with patients with diabetes provided by nurses in GP practices is associated with control of diabetes measured by levels of glycated haemoglobin (HbA1c). Design and Setting: A retrospective observational study using consultation records from 319 649 patients with diabetes from 471 UK general practices from 2002 to 2011. Method: Hierarchical multilevel models to examine associations between proportion of consultations undertaken by nurses and attaining HbA1c targets over time, controlling for case-mix and practice level factors. Results: The proportion of consultations with nurses has increased by 20% since 2002 but patients with diabetes made fewer consultations per year in 2011 compared with 2002 (11.6 versus 16.0). Glycaemic control has improved and was more uniformly achieved in 2011 than 2002. Practices in which nurses provide a higher proportion of consultations perform no differently to those where nurse input is lower (lowest versus highest nurse contact tertile odds ratio [OR] [confidence interval {95% CI}]: HbA1c ≤53 mmol/mol (7%) 2002, 1.04 [95% CI = 0.87 to 1.25] and 2011, 0.95 [95% CI = 0.87 to 1.03]; HbA1c ≤86 mmol/mol (10%) 2002, 0.97 [95% CI = 0.73 to 1.29] and 2011, 0.95 [95% CI = 0.86 to 1.04]). Conclusion: Practices that primarily use GPs to deliver diabetes care could release significant resources with no adverse effect by switching their services towards nurse-led care. [ABSTRACT FROM AUTHOR]

Background: Demand for England's accident and emergency (A&E) services is increasing and is particularly concentrated in areas of high deprivation. The extent to which primary care services, relative to population characteristics, can impact on A&E is not fully understood. Aim: To conduct a detailed analysis to identify population and primary care characteristics associated with A&E attendance rates, particularly those that may be amenable to change by primary care services. Design and Setting: This study used a cross-sectional population-based design. The setting was general practices in England, in the year 2011-2012. Method: Multivariate linear regression analysis was used to create a model to explain the variability in practice A&E attendance rates. Predictor variables included population demographics, practice characteristics, and measures of patient experiences of primary care. Results: The strongest predictor of general practice A&E attendance rates was social deprivation: the Index of Multiple Deprivation (IMD-2010) (β = 0.3. B = 1.4 [95% CI =1.3 to 1.6]), followed by population morbidity (GPPS responders reporting a long-standing health condition) (β = 0.2, B = 231.5 [95% CI = 202.1 to 260.8]), and knowledge of how to contact an out-of-hours GP (GPPS question 36) (β = -0.2, B = -128.7 [95% CI =149.3 to -108.2]). Other significant predictors included the practice list size (β = -0.1, B = -0.002 [95% CI = -0.003 to -0.002]) and the proportion of patients aged 0-4 years (β = 0.1, B = 547.3 [95% CI = 418.6 to 676.0]). The final model explained 34.4% of the variation in A&E attendance rates, mostly due to factors that could not be modified by primary care services. Conclusion: Demographic characteristics were the strongest predictors of A&E attendance rates. Primary care variables that may be amenable to change only made a small contribution to higher A&E attendance rates. [ABSTRACT FROM AUTHOR]

Background Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care. Aim The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care. Design and setting Retrospective cross-sectional study in general practices in England. Method Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. Outcome measures: multilevel regression models adjusted for clustering. Results GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the 'doctor care' (n = 6) and 'overall satisfaction' (n = 2) domains but not to any of the 'nurse care' or 'out-ofhours' domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients. Conclusion Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as 'listening' or 'care and concern'. [ABSTRACT FROM AUTHOR]

Objective: To determine the characteristics of general practices which perform poorly in terms of Quality and Outcome (QOF) performance indicators in England's NHS. Method: Retrospective, four year longitudinal study, 2005 to 2008. Data were obtained from 8515 practices (99% of practices in England) in year 1, 8264 (98%) in year 2, 8192 (98%) in year 3 and 8256 (99%) in year 4. Outcome measures: QOF performance scores; social deprivation (IMD-2007) and ethnicity from the 2001 national census; general practice characteristics. Results: We identified a cohort of 212 (2.7%) practices which remained in the lowest decile for total QOF scores in the four years following the introduction of the QOF. A total of 705,386 patients were registered at these practices in year 4. These practices were more likely to be singlehanded (odds ratio [OR], 13.8), nontraining practices (OR, 3.9) and located in deprived areas (OR, 2.6; most vs least deprived quintiles). General practitioners (GPs) in these practices were more often aged ⩾65 years or more (OR, 7.3; mean GP age ⩾65 years vs <45 years), male (OR 2.0), UK qualified (OR 2.0) with small list sizes (OR 3.2; list size <1000 vs 1500-2000 patients). We identified individual QOF indicators which were poorly achieved. The reported prevalence of most chronic diseases was lower in the poorly performing cohort. Conclusions: A small minority of practices have remained poor performers in terms of measurable performance indicators over a four-year period. The strongest predictors of poor QOF performance were singlehanded and small practices, and practices staffed by elderly GPs. [ABSTRACT FROM AUTHOR]

Background: The purpose of this research is to develop and evaluate methods for conducting cluster randomised trials in a primary care database that contains electronic patient records for large numbers of family practices. Cluster randomised trials are trials in which the units allocated represent groups of individuals, in this case family practices and their registered patients. Cluster randomised trials often suffer from the limitation that they include too few clusters, leading to problems of insufficient power and only imprecise estimation of the intraclass correlation coefficient, a key design parameter. This difficulty might be overcome by utilising databases that already hold electronic patient records for large numbers of practices. The protocol describes one application: a study of antibiotic prescribing for acute respiratory infection; a second protocol outlines an intervention in a less frequent chronic condition of public health importance, stroke.Methods/design: The objective of the study is to implement a cluster randomised trial to test the effectiveness of an electronic record-based intervention at achieving a reduction in antibiotic prescribing at consultations for respiratory illness in patients aged 18 and 59 years old in intervention family practices as compared with controls. Family practices will be recruited from the practices that presently contribute data to the UK General Practice Research Database (GPRD). Following randomisation, electronic prompts will be installed remotely at intervention practices to promote adherence with evidence-based standards of medical practice. The intervention was developed through qualitative research at non-intervention practices. Data for outcome assessment will be obtained from anonymised electronic patient records that are routinely collected into GPRD. This protocol outlines the proposed study designs, data sources, sample size requirements, analysis methods and dissemination plans. Ethical issues are also discussed.Discussion: Results from this study will provide methodological evidence concerning the use of electronic patient records and databases for implementing cluster randomised trials in primary care. The study will also provide substantive findings in respect of electronic record-based interventions to reduce antibiotic prescribing in primary care.Trial Registration: Current Controlled Trials ISRCTN 47558792. [ABSTRACT FROM AUTHOR]

Referrals for psychological treatment have been problematic for many years. Even though GPs have attempted to limit access into the small psychological treatment services, long waiting lists have developed which have deterred referrals and deferred psychological care. GPs have understandably been frustrated. In addition, the consultation rate for psychological problems is low when compared with the rate of identified mental health problems in population surveys, possible reasons include patients' failure to recognise the problem as psychological and thus not consulting one's GR and/or the problem not being detected by the GP. While a self-referral system may be seen as a way of trying to allow non-consulters to receive treatment, this has been viewed with some scepticism since it may allow the 'worried well' to access already limited services. However, a study has shown that those self-referring to advertised psychological workshops had high levels of psychological morbidity and also were more representative of the population, in terms of ethnicity, than GP referrals. The government has set up the Increasing Access to Psychological Therapies (IAPT) programme to address some of the service shortfalls by expanding the provision of psychological therapists. Notably, the IAPT programme is allowing self-referrals such that any member of the public can access the service directly, bypassing general practice, Although not available at all the sites, this represents a radical shift from the present system in which access to talking therapy is generally only available through direct referral by the GR. The implications of this new development are discussed. [ABSTRACT FROM AUTHOR]

Background In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a 'pay for performance' scheme. Aim To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF. Design of the study Cross-sectional analysis of routine data. Setting English general practice in 2005/2006. Method QOF data from 7456 general practices Were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per fulltime equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it. Results A high level of nurse staffing (fewer patients per fulltime equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary hear[ disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA1c] ≤7.4%, HbA1c ≤10% and total cholesterol ≤ 193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001). Conclusion Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets. [ABSTRACT FROM AUTHOR]

Background: Electronic patient records from primary care databases are increasingly used in public health and health services research but methods used to identify cases with disease are not well described. This study aimed to evaluate the relevance of different codes for the identification of acute stroke in a primary care database, and to evaluate trends in the use of different codes over time. Methods: Data were obtained from the General Practice Research Database from 1997 to 2006. All subjects had a minimum of 24 months of up-to-standard record before the first recorded stroke diagnosis. Initially, we identified stroke cases using a supplemented version of the set of codes for prevalent stroke used by the Office for National Statistics in Key health statistics from general practice 1998 (ONS codes). The ONS codes were then independently reviewed by four raters and a restricted set of 121 codes for 'acute stroke' was identified but the kappa statistic was low at 0.23. Results: Initial extraction of data using the ONS codes gave 48,239 cases of stroke from 1997 to 2006. Application of the restricted set of codes reduced this to 39,424 cases. There were 2,288 cases whose index medical codes were for 'stroke annual review' and 3,112 for 'stroke monitoring'. The frequency of stroke review and monitoring codes as index codes increased from 9 per year in 1997 to 1,612 in 2004, 1,530 in 2005 and 1,424 in 2006. The one year mortality of cases with the restricted set of codes was 29.1% but for 'stroke annual review,' 4.6% and for 'stroke monitoring codes', 5.7%. Conclusion: In the analysis of electronic patient records, different medical codes for a single condition may have varying clinical and prognostic significance; utilisation of different medical codes may change over time; researchers with differing clinical or epidemiological experience may have differing interpretations of the relevance of particular codes. There is a need for greater transparency in the selection of sets of codes for different conditions, for the reporting of sensitivity analyses using different sets of codes, as well as sharing of code sets among researchers. [ABSTRACT FROM AUTHOR]

Background: Antidepressant prescribing should reflect need. The Quality and Outcomes Framework has provided an opportunity to explore factors affecting antidepressant prescribing in UK general practice.Aims: To explore the relationship between physical illness, social deprivation, ethnicity, practice characteristics and the volume of antidepressants prescribed in primary care.Method: This was an ecological study using data derived from the Quality and Outcomes Framework, the Informatics Collaboratory of the Social Sciences, and Prescribing Analyses and CosT data for 2004-2005. Associations were examined using linear regression modelling.Results: Socio-economic status, ethnic density, asthma, chronic obstructive pulmonary disease and epilepsy explained 44% of the variance in the volume of antidepressants prescribed.Conclusions: Lower volumes of antidepressants are prescribed in areas with high densities of Black or Asian people. This may suggest disparities in provision of care. Chronic respiratory disease and epilepsy may have a more important association with depression in primary care than previously thought. [ABSTRACT FROM AUTHOR]

Background: The descriptive information now available for primary care in the UK is unique in international terms. Under the 'Quality and Outcomes Framework' (QOF), data for 147 performance indicators are available for each general practice. We aimed to determine the relationship between the quality of primary care, as judged by the total QOF score, social deprivation and practice characteristics. Methods: We obtained QOF data for each practice in England and linked these with census derived data (deprivation indices and proportion of patients born in a developing country). Characteristics of practices were also obtained. QOF and census data were available for 8480 practices. Results: The median QOF score was 999.7 out of a possible maximum of 1050 points. Three characteristics were independently associated with higher QOF scores: training practices, group practices and practices in less socially deprived areas. In a regression model, these three factors explained 14.6% of the variation in QOF score. Higher list sizes per GP, turnover of registered patients, chronic disease prevalence, proportions of elderly patients or patients born in a developing country did not contribute to lower QOF scores in the final model. Conclusion: Socially deprived areas experience a lower quality of primary care, as judged by QOF scores. Social deprivation itself is an independent predictor of lower quality. Training and group practices are independent predictors of higher quality but these types of practices are less well represented in socially deprived areas. [ABSTRACT FROM AUTHOR]

The authors present a reply to comments on their study on the influence of prior antibiotic use on risk of rheumatoid arthritis (RA). Topics covered include the difficulty of disentangling the antibiotic-infection relationship, and the speculation that microbiome damage may be linked to the observations made. Also noted are the authors' inability to comment on whether neutrophil traps were implicated in the link of antibiotics to RA.

Objective: The aim of the present study was to determine the relationship between the characteristics of general practices and the perceptions of the psychological content of consultations by GPs in those practices.Methods: A cross-sectional survey was conducted of all GPs (22 GPs based in nine practices) serving a discrete inner city community of 41 000 residents. GPs were asked to complete a log-diary over a period of five working days, rating their perception of the psychological content of each consultation on a 4-point Likert scale, ranging from 0 (no psychological content) to 3 (entirely psychological in content). The influence of GP and practice characteristics on psychological content scores was examined.Results: Data were available for every surgery-based consultation (n = 2206) conducted by all 22 participating GPs over the study period. The mean psychological content score was 0.58 (SD 0.33). Sixty-four percent of consultations were recorded as being without any psychological content; 6% were entirely psychological in content. Higher psychological content scores were significantly associated with younger GPs, training practices (n = 3), group practices (n = 4), the presence of on-site mental health workers (n = 5), higher antidepressant prescribing volumes and the achievement of vaccine and smear targets. Training status had the greatest predictive power, explaining 51% of the variation in psychological content. Neither practice consultation rates, GP list size, annual psychiatric referral rates nor volumes of benzodiazepine prescribing were related to psychological content scores.Conclusion: Increased awareness by GPs of the psychological dimension within a consultation may be a feature of the educational environment of training practices. [ABSTRACT FROM AUTHOR]

The author discusses the risk of financial incentives such as the Quality and Outcomes Framework (QOF) in general practice. Topics discussed include the approach of the National Institute for Health and Care Excellence to assess indicators of the QOF, the six direct enhanced services (DESs) implemented in England to incentivised clinical behaviours such unplanned admissions and learning disability, and the benefits of co-creation in the practice to achieve quality improvement.

The author reflects on the general practices (GPs) in Great Britain, focusing on the standards of quality. He states that the dominant method of data facilitation in GP is the Quality and Outcomes Framework (QOF), which was introduced in 2004. He mentions that QOF monitoring resulted in the creation of the largest GP database in the world, prompting research around processes and outputs and their relationship to outcomes in GP.