Jeremy Dale

Background: Interdisciplinary working for the safety improvement of older patients’ care after discharge is complex. As part of the General Practice Management After Transitions Events (GP‐MATE) study, a consensus workshop was convened bringing together patients, carers, secondary and primary care clinicians to co‐produce and prioritise recommendations for how a patient‐directed post‐discharge communication tool for older people should be implemented in the NHS. Methods: We conducted a day‐long, face‐to‐face consensus workshop involving 21 participants: 10 patients, carers and public representatives; 5 secondary care frailty leaders and 6 general practice leaders. Using Nominal Group Technique, in small groups participants generated statements based on pre‐identified key ‘tensions’ derived from the 4‐year GP‐MATE study. These were then combined and moderated by the wider group and rated for acceptability and feasibility using RAND/UCLA voting across two rounds; round 2 conducted online. Results: Participants produced 52 statements; 35 were considered acceptable and feasible. The highest‑ranked emphasised patient autonomy, clarity of purpose, and involvement of community‑based professionals (including District Nursing and Urgent Community Response teams) to reach frail or housebound patients. Complete digitisation was the only statement rated inappropriate. The importance of distinguishing GP‐MATE from current ways of working was also prioritised. Conclusion: The workshop generated a set of co‑produced, theory‑informed recommendations to guide a definitive trial of GP‑MATE and support wider implementation of patient‑held communication tools in post‑discharge care. The study also demonstrated that RAND/UCLA can be successfully adapted for co‑production with mixed Public and Patient Involvement (PPI) and professional groups. Patient or Public Contribution: The GP‐MATE study was centred on Experience‐Based Co‐Design as a method for participatory action research. We began with a patient experience film featuring patients from general practice in the West‐Midlands. Our intervention was developed by three teams of older patients and carers of older persons and is reported in the US patient‐focused journal Patient Education and Counselling. In the workshop described in this paper, patients and their carers were brought to power by working in parity of numbers with hospital professionals in smaller breakout groups. Our three breakout groups were planned to be co‐facilitated by PPI‐E contributors (but on the day, only one was well enough to undertake this role). We also included a local Healthwatch lead among our participants.

Background The National Health Service (NHS) aims to reach net zero by 2040. Although recognised as having a key role, little is known about how decarbonisation initiatives are implemented in general practice and how progress can be supported. Aim To explore the institutional, organisational and professional factors that influence implementation of decarbonisation actions in general practice over time. Design and setting Longitudinal qualitative case study in 12 general practices in England. Methods Practices developed a Green Action Plan (GAP) comprising 3-5 measurable actions to be implemented over 12 months. Qualitative data were collected through baseline workshops, 3-monthly follow‑up ‘check-in’ discussions and final focus groups. Topic guides were iteratively developed, informed by Normalisation Process Theory and the Theoretical Domains Framework, and Framework analysis was conducted Results The factors influencing decarbonisation are presented as five themes: systemic barriers; culture and communication; capacity and competing demands; ‘making it work’; and behaviour, attitudes and feelings. Actions aligned with wider NHS priorities or offering time/financial efficiency were easier to embed, whereas those requiring individual behaviour change or reliant on external systems were more challenging. Lack of coordinated policy support and limited control over estates and infrastructure constrained progress. Conclusion At practice level, actions that integrate into routine work and provide efficiency gains are most feasible in enacting change. To support sustained change, directive national policies and coordinated system-level support are required. Individual behaviour change is challenging in an already pressured system, but a supportive culture and team collaboration can facilitate progress.

Objective: General Practice Management After Transition Events (GP-MATE) is a codesigned patient-held tool to structure a dedicated postdischarge appointment for older patients. This pilot in routine general practice evaluated its feasibility (recruitment, tool use), acceptability (staff/patient views), potential outcomes (error, harm and readmission) and healthcare cost implications. Design and setting: Seven diverse general practices in the West Midlands, England, participated in this 4-year mixed-methods National Institute for Health and Care Research-funded study. A 20-minute GP-MATE appointment was offered to all patients aged >65 recently discharged from the hospital, supported by a paper-based communication tool sent to those who accepted. Three months of free-text electronic health records were reviewed for care use, intervention coverage, error, harm and readmission. Attributable healthcare costs were assessed. Patient/carer surveys and interviews with patients, carers and healthcare professionals explored experiences of delivery and use. Participants: 40 patients (mean age 75 years; 53% female) attended GP-MATE appointments, and 29 returned surveys. 17 patient-held GP-MATE forms were retrieved and analysed. Seven patients/carers and nine healthcare professionals were interviewed. Results: Care appeared safe, with tentative signs of being two-thirds less error prone ( X ² =3.48 on 1df, p=0.06); no harms were detected. Postdischarge general practice use was high, with 115 admission-related contacts; almost two-thirds of the cohort had already received discharge-related care before GP-MATE. Despite this, GP-MATE appointments addressed persistent gaps in discharge information, leading to meaningful changes in care (mean=2.6 per patient), including new referrals and medication changes. Intervention costs represented just over half of the total mean attributable general practice care costs. Staff and patient/carer experiences indicate acceptability, though some unwell or confused patients struggled to differentiate the GP-MATE intervention from usual care. The perceived benefits were lower for elective or less complex admissions. Practices reported mixed experiences, including administrative difficulties in booking appointments and high non-attendance rates. Conclusion: GP-MATE was feasible to deliver, acceptable to staff and patients/carers and supported postdischarge communication. Larger trials are needed to establish robust evidence of readmission reduction and error/harm reduction, equity and cost-benefit.

Background: Most hospital admissions are older patients, who are more likely to be medically complex. Primary care risks after hospital discharge and readmission trajectories are relatively unexplored. Aim: To estimate the frequency and nature of errors and harms linked to discharge summary processing in general practice for patients aged ≥65 years and explore associations with readmission and healthcare utilisation from a novel primary care data source. Design and Setting: Retrospective cohort study using electronic health records (EHRs) from seven purposively sampled general practices in the West Midlands, UK. Method: We reviewed EHRs for 263 patients aged ≥65 years discharged between October 2022-2023. Outcomes included post-discharge healthcare utilisation and costs, frequency and type of discharge actions, error rates (failures to complete requested actions), harms (severity, attribution, preventability), and 90-day readmissions. Multivariable logistic regression identified predictors of errors, harms and readmission. Results: 186/263 discharged patients (70.7%) accessed post-discharge care; with 47/263 patients 17.5% (95% CI: 13.7-23.0%) having related readmissions within 90 days. The 263 discharge summaries requested 551 actions; 21.3% were not completed, over half involving medications. 12.5% of patients experienced error, 4.4% experienced harm. Most harms were preventable and resulted in hospital readmission. Error/harm disproportionately affected patients with dementia or recorded carer. Conclusion: General practice needs to review their processes for responding to patient discharge information in order to improve patient safety post-discharge. Further research into tools to assist practice with transitions is warranted.

Aim: To describe the development, delivery, and outcome of an action-oriented intervention comprising an awareness-raising educational video and workshop designed to support general practice teams to identify and plan decarbonization actions, delivered from May-September 2024. Background: Healthcare services internationally are committing to net zero targets. General practice is recognized as having a pivotal role in achieving these ambitions. However, limited awareness of decarbonization initiatives and insufficient support for implementation highlight the need for an educational resource to facilitate action planning. Methods: Principles of organizational change, video-design, and barriers to decarbonization informed the intervention’s development. The video included modules featuring resource materials and ideas to support the development and implementation of decarbonization actions in general practice. Prompts for a facilitated workshop discussion were developed to support action planning. The intervention was delivered to 64 multidisciplinary staff across 12 general practices in England. A conceptual content analysis was conducted on completed practice green action plans (GAPs) and data from an online participant feedback form were analysed using descriptive statistics to assess perceptions of the intervention. Free-text comments were thematically analysed. Results: Across the 12 GAPs, each practice planned between three and eight decarbonization actions. ‘Managing waste’ was the most frequently addressed area, appearing in 10 practice GAPs, and most planned actions mapped onto those presented within the video. Thirty (46.9%) participants completed the evaluation survey. The intervention was well received, with 28 (93.3%) survey respondents rating the overall usefulness of the video as 4 or 5 (1 ‘not at all useful’ to 5 ‘very useful’). Free-text comments for suggested improvements related to time for consolidating learning, and concerns about the video’s audio quality and duration. Conclusions: The educational workshop successfully facilitated the development of structured GAPs with explicit timescales and intended outcomes. This study did not assess the implementation of planned actions.

Background: People of Black African and Black Caribbean ethnicity experience higher rates and poorer outcomes of type 2 diabetes (T2D) than people of White European ethnicity; these inequalities are compounded by poor healthcare access. Cultural tailoring of diabetes self-management education and support (DSMES) programs has the potential to improve healthcare engagement and clinical outcomes for ethnic minority groups. Healthy Eating & Active Lifestyles for Diabetes (HEAL-D) is a co-designed, culturally tailored group-based DSMES program for adults of Black African and Black Caribbean ethnicity. Objective: This trial aims to evaluate the clinical and cost effectiveness of the HEAL-D intervention, compared to standard DSMES programs, in Black African and Black Caribbean adults living with T2D. Methods: A 24-month, multicenter, pragmatic, open-label, 2-arm, parallel-group, individually randomized group treatment trial will be conducted, with primary end point (glycated hemoglobin [HbA1c]) assessment at 12 months. Black African and Black Caribbean adults with T2D (n=300), recruited from 3 to 5 centers in the United Kingdom (including London, West Midlands, and Greater Manchester), will be randomized in a 1:1 ratio to HEAL-D (intervention) or a standard DSMES program (control). HbA1c, blood lipids, anthropometric outcomes, blood pressure, physical activity, and patient-reported outcome measures relating to psychological well-being and self-management support, lifestyle behaviors, and health economics will be collected at baseline and follow-up visits (6, 12, and 24 months). Cost-effectiveness will be assessed through a cost-utility analysis conducted from a health and social care perspective. A mixed methods process evaluation will provide a formative evaluation of delivery, intervention fidelity, and implementation of HEAL-D, and an embedded study within a project will assess the impact of multiple long-term conditions on uptake of, and engagement with HEAL-D, and the impact of HEAL-D on multiple long-term conditions. The trial received Research Authority and Research Ethics Council approval on April 22, 2024. Results: Funding began in August 2023. Site “green light” was received on August 15, 2024, for London; November 29, 2024, for Manchester; and January 31, 2025, for the West Midlands. Recruitment commenced in August 2024 and is due to run for 11 months. As of March 26, 2025, a total of 76 participants have consented. Last patient, last visit is expected in June 2027; primary data analysis is expected to begin in July 2027. Final results are anticipated to be available in September 2027, and publication is expected by the end of 2027. Conclusions: The HEAL-D trial will address whether a culturally tailored DSMES program, provided in-person or via videoconferencing, is clinically and cost-effective compared to standard DSMES at improving diabetes management in Black African and Black Caribbean adults. If effective, this would provide an evidence-based model of equitable DSMES services and improve the implementation of healthcare programs for ethnic minority groups. Trial Registration: ISRCTN 1434448; https://www.isrctn.com/ISRCTN14344948 International Registered Report Identifier (IRRID): DERR1-10.2196/71861

Objectives: To describe current levels of interest and action around decarbonisation in general practice settings, and awareness and use of currently available materials designed to support general practice teams undertake decarbonisation activity. Design: Cross-sectional, mixed methods, online survey. Setting: 473 general practices in three Integrated Care Board regions in England. Participants: Multiprofessional general practice staff. Results: There were 328 responses from 163 (34.5%) practices. Most respondents were general practitioner (GP) partners (98; 29.9%), other clinical staff (93; 28.3%) or managerial staff (76; 23.2%). 229 (69.8%) respondents felt that acting to reduce carbon emissions from primary care is a legitimate part of general practice activity. However, only 44 (13.4%) felt that there is sufficient training and resources to support such activity, and only 59 (18.0%) agreed that there was sufficient leadership from higher levels within the health service to enable this. 58 (35.6%) practices had a lead for sustainability, generally managerial staff (22; 37.9%) or GP partners (17; 29.3%). Compared to other practices, those with a decarbonisation lead reported increased levels of decarbonisation actions currently being undertaken (mean = 5.2 vs 3.1; t(161) = 7.7, p2 =31.9, p2 =32.3, p<0.001). Respondents from 47 (28.8%) practices provided free-text comment, mostly noting conflicting workload priorities, limited funding, lack of leadership and practice staff engagement as barriers to decarbonisation activity in their practice. Conclusions: This survey provides insight into how English general practices and their staff regard decarbonisation activities. The findings highlight the importance of leadership, resources and incentives in driving such activities and have implications for initiatives to help achieve wider decarbonisation goals in healthcare.

Background: Women from lower socioeconomic status and minority ethnic backgrounds have earlier onset and more complex menopause symptoms. Hormone replacement therapy (HRT) has grown in popularity in recent years, however there are stark disparities in those who access HRT. Rates of use in deprived areas and for Black and Asian women are significantly lower than that of White women and those in more affluent areas. Aim: To explore women’s experiences of menopause and accessing primary care, as well as how perceptions and approaches may be shaped by cultural norms, to gain deeper understanding of factors shaping approaches to managing menopause and HRT prescribing patterns. Design & setting: Qualitative study with women recruited from general practice and community networks. Method: In-depth semi-structured interviews and focus groups with women experiencing menopause ( n = 40) were conducted between October 2023 and March 2024. Purposive sampling allowed a breadth of experiences and thematic analysis was conducted. Results: Three themes were developed in relation to women’s experiences of accessing menopause care: 1) ‘Contemporary contexts’ shaped women’s experiences; managing menopause alongside high workloads and caring responsibilities posed challenges perceived as distinct from previous generations; and there was heightened awareness, reduced stigma, and mixed views regarding HRT; 2) ‘How menopause care is experienced’ demonstrated how consultations about menopause were emotionally charged, many felt they would have to advocate for HRT (if they wanted it), and some felt frustrated with the lack of options available; and 3) ‘Cultural and economic background influences on menopause help seeking’ included how some women from Black or Asian backgrounds did not discuss menopause within their communities. Mistrust of medical institutions and treatments, as well as lack of representation, was problematic for Black and Asian participants. Some women worried about stereotyping during consultations. Conclusion: The findings outline how menopause may be particularly disruptive to modern women, demonstrate how women are often dissatisfied with the options available, and highlight key areas, such as communication about HRT benefits and/or risks, which could be improved in primary care settings.

The Women’s Health Strategy for England reported that only 9% of 100 000 responders to the ‘Women’s Health — Let’s talk about it’ survey said that they had sufficient information about menopause and its treatment.⁵ To improve this, we need to understand the complexities of decision making around HRT and develop individualised discussion and decision aids to help women and their HCPs navigate treatment decisions about starting and stopping HRT.¹,⁶

Background: In the UK, there is increasing public awareness of menopause. However, there remain inequalities in its treatment, with lower hormone replacement therapy (HRT) prescribing in areas of social deprivation. Little is known about how healthcare professionals (HCPs) view and understand this inequality. Aim: To explore barriers to, and facilitators of, the provision of menopause care in diverse communities. Design and setting: Qualitative, semi-structured interviews were conducted with HCPs across central England. Method: The authors purposively sampled 15 HCPs working in patient-facing roles in areas of high deprivation. An interview schedule was developed, and 11 individual interviews and one focus group were conducted between January and March 2024. The data were subject to team-based iterative thematic analysis. Results: Data were categorised into three key themes: the context of contemporary primary care, delivering menopause care, and limitations of the current approach to menopause care. HCPs reported that awareness of menopause and requests for HRT were increasing, but cultural and ethnic differences were perceived as affecting whether women sought menopause care and/or HRT from their GP. HCPs believed women had high expectations of HRT and felt that discussions around realistic expectations were important. They also emphasised: the difficulty of remaining up to date on menopause care; there being limited time, resources, and ability to refer to specialists; the impact of patients’ requests for testosterone; the need for targeted, culturally sensitive patient outreach initiatives and education; and the need for dedicated training for HCPs. Conclusion: HCPs believed that differences in levels of menopause care across diverse populations that experienced health inequalities reflected differing demands from communities, as well as a lack of time and funding to provide targeted community-based education on menopause and its treatment. Future work to improve menopause care should include additional research as well as culturally sensitive and targeted health education for patients and HCPs.