Jon Mark Dickson

Background: Statins are the UK’s most prescribed medicine and are used more in deprived populations. Patient Information Leaflets (PILs) included in medication packaging may support safe, effective use, but only if they are understandable. Guidance states PILs should have a reading age of ≤13 years, and regulators require that ≥80% of patients answer comprehension questions correctly on them when ‘user tested’. Aim: To provide the first independent evaluation of the readability and comprehension of UK statin PILs. Design & setting: Study 1: Cross-sectional analysis of the reading age of 39/40 of the UK’s approved statin PILs. Study 2: Cross-sectional survey with a representative sample of 517 UK adults aged 40–74. Methods: Study 1: Reading age was assessed using four readability formulas, with additional scores calculated after adjusting for potentially familiar technical terms. Study 2: Two PILs (atorvastatin [MSN] and rosuvastatin [Ranbaxy]) were randomly selected and user-tested with participants. They answered eight comprehension questions per PIL; responses were double-scored. Results: Study 1: No PIL met the recommended reading age. Median reading age was 15.9 years (15.0 after adjustment). Atorvastatin PILs were least readable. Study 2: Key messages were poorly understood; for atorvastatin, 5/8 items met the≥80% criterion; for rosuvastatin, 2/8 met it. Key safety and use messages were frequently misunderstood. Conclusion: UK statin PILs do not meet recommended readability or comprehension standards and are likely to be difficult to understand for many users. Improving clarity and usability is essential to support equitable understanding and safe, informed long-term statin use.

Background The memory assessment pathway for people with subjective memory deficits (dementia, mild cognitive impairment, and other diagnoses) is under huge strain and new diagnostic technologies have been identified as a high priority for research. Aim To investigate the views of GPs on the memory assessment pathway, and on how an artificial intelligence tool (CognoSpeak^TM) could be implemented. Design & setting Qualitative interview study in a large region of the NHS (South Yorkshire). Method Recruitment of 18 GPs using convenience sampling to undertake semi-structured interviews, analysed using reflexive thematic analysis (demographic data was monitored to ensure diversity). Results GPs think that the memory assessment pathway has system-wide problems, and that GPs are overworked yet underutilised. They highlighted assessment/referral dilemmas, and the perspectives of patients and families. When asked about implementation of CognoSpeak^TM they gave their thoughts on the optimal sites of implementation, they highlighted barriers/ difficulties, as well as the opportunities/benefits, and they made proposals for the future development of CognoSpeak^TM. Conclusion GPs thought effective implementation of CognoSpeak^TM could save time, expedite diagnosis, free-up much needed capacity, and improve the longitudinal assessment of people with mild cognitive impairment. A major concern amongst GPs was the potential for unintended consequences such as creating additional unfunded work, and exacerbating difficulties at the intersections between subjective memory deficits and other factors such as low mood, alcohol excess, learning difficulties, language and culture. They were concerned about poor access to technology amongst old and economically deprived people.

Background: Good quality primary care is essential for the assessment and treatment of headache but there is evidence that primary care for headache is suboptimal. Aim: To identify the international evidence on the assessment and treatment of headache in adults in primary care. Design & setting: A scoping review of the published literature following Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SCR) guidelines, and a narrative review of the evidence. Method: An electronic search of MEDLINE and Embase (1974–2024) was undertaken. Studies meeting the eligibility criteria were included. Results were grouped by study type and were reported narratively. Results: In total, 1125 articles were screened, 43 articles underwent full-text review, and 28 articles were included in the final review. Six studies used comparative methods, of which n = 3/6 investigated educational interventions. The educational interventions found positive effects on learning, and on outcomes such as diagnosis rates, but the only randomised controlled trial (RCT) did not show any benefits of the intervention. Other comparative studies showed satisfaction with GP with an extended role (GPwER) headache services, benefits from direct access to magnetic resonance imaging (MRI), and benefits from a nurse-led headache service. Twenty-two studies used non-comparative methods, such as surveys and interviews, and investigated approaches to assessment, diagnosis, referral rationale, decision making for prescribing prophylactic medications, educational initiatives, direct access to neuroimaging, GPwER, and nurse-led interventions. Conclusion: Despite the availability of high quality clinical guidelines on the assessment and management of headache, the evidence shows that its implementation in primary care is problematic and educational interventions are a common focus of published studies. Further research is required to assess the quality of the current evidence and to develop, refine, and deploy interventions that have a signal of efficacy.

Everyone should have the opportunity to participate in decisions about their health, including people living with dementia. People with dementia typically bring a companion to medical appointments, so most care decisions are made in interactions involving three parties. To make decisions about their care, patients with dementia must have the opportunity to take a turn-at-talk in conversations where decisions are made. However, negotiating who speaks next in triadic talk is a complex task, especially when dementia-associated language and/or memory problems impact communication. Findings show that using second person (“you”) pronouns assist people with dementia in responding to queries, yet third person (“she/he”) can exclude them from the interaction, although this near-canonical pronoun use can be overridden by sequential placement, gesture, and gaze. We also demonstrate how midturn pronoun switching often only provides for tokenistic inclusion, though this again is dependent on sequential placement and embodied interaction. Data are in English.

Background: GPs are often required to make decisions about the management of acute illness in people living with dementia. These decisions are often complex and involve multiple informants.Aim: We aimed to explore how GPs made decisions about acute illness in people with dementia using a micropolitics approach.Design & setting: Qualitative, semi-structured interviews with 13 GPs with a range of years of experience working in South Yorkshire, UK.Method: Interviews were conducted by phone. Interviews focused on GPs’ accounts to reflect their own perceptions and choices as portrayed to the interviewer. The analysis used the lens of micropolitics in the analysis and interpretation of the themes, with a focus on decisions between GP, patient, family and carers, and other health and social care providers about the management of acute illness in a person with dementia.Results: The results showed that GPs act as street-level bureaucrats while carrying out their role, using discretion during decision-making in an environment characterised by uncertainties and work pressures. In addition, GPs use the ‘soft power’ skills of diplomacy, such as negotiation, persuasion, and engagement, in navigating difficult decision-making situations, while building relationships and partnerships with various actors in the health system.Conclusion: GPs possess and express power, and influence decision-making in people living with dementia when navigating biomedical, social, and psychological factors. This power comes in the form of soft power (street-level diplomacy) and the more formal power of street-level bureaucracy.

Background: In the UK, epilepsy care involves both specialists (for example, neurologists) and generalists (for example, GPs). Policymakers typically consider that epilepsy care should be integrated and involve both specialists and generalists. However, few understand exactly how patients view and compare specialist and generalist care. Aim: To explore patient perspectives of specialist care and generalist care for epilepsy in a qualitative evidence synthesis. Design & setting: A systematic review of patient perspectives of epilepsy care. A qualitative evidence synthesis was conducted using an identified framework. Method: Systematic searches in five databases retrieved 17 eligible studies. Data were extracted and synthesised using framework analysis informed by the ‘United Model of Generalism’. Results: The following three themes were developed: ‘Epilepsy care can be burdensome’ (for example, through care fragmentation); ‘Patients' experiences of care is that care is not always accessible’ (for example, lack of a continuum between standardised and interpretive care); and ‘How care could change for people with epilepsy’ (for example, clinicians currently have insufficient time to deviate from protocol-driven care to address psychosocial needs). People with epilepsy frequently observe that generalists lack expertise in epilepsy management. Conclusion: This synthesis of patient experiences indicates recommendations should focus on improving communication and integration between specialists and generalists for epilepsy care. Patient experiences indicate specialist care risks being burdensome and generalist knowledge insufficient, requiring enhanced primary care clinician skills and improved awareness of patient psychosocial needs. The findings argue in favour of healthcare policies, materials, and tools to continually support patient perspectives in developing epilepsy services.

Background: Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible. Objective(s): (1) Identify configurations being considered, (2) understand service users’ views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users’ preference and being National Health Service-feasible. Design: Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users’ care preferences for different seizure scenarios. Objective 4 was addressed by completing ‘knowledge exchange’ workshops. At these, stakeholders considered the findings on users’ stated preferences and judged different pathway configurations against Michie’s ‘acceptability, practicability, effectiveness, affordability, side-effects and equity’ feasibility criteria. Setting: This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks. Participants: Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders. Results: The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5–10 years, with some elements being immediately deployable. Limitations: The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented. Conclusions: Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy. Study registration: The study is registered as researchregistry4723. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.