Emilie Couchman

Background: Continuity has benefits at individual and organisational levels but is compromised by challenges within healthcare systems internationally. This paper describes a new theoretical framework entitled ‘CAP Continuity’, which was developed within a realist evaluation exploring continuity in UK general practice for people with mesothelioma. It highlights three key elements of continuity: competence, attitude, and provision. Approach: Nine patient case studies were formed through longitudinal realist interviews. Data were triangulated by also interviewing healthcare professionals (n=12) and close persons (n=9). The analytical approach to the development of the new theoretical framework consisted of three concurrent components: reflexive thematic analysis of the interview transcripts; the development of realist Context-Mechanism-Outcome configurations; and the application of two existing theories (the Burden of Treatment Theory and the Candidacy Framework). Results: The CAP Continuity framework stipulates that healthcare professionals and patients must be sufficiently competent to provide care or navigate the system to receive such care (competence); each party within the clinician-patient relationship, and the wider healthcare team, requires an attitude that reflects appreciation of the value of continuity (attitude); and the healthcare system must be adequately resourced, both physically and strategically (provision). Implications: The CAP Continuity framework does not seek to replace existing definitions of continuity, but to help integrate such definitions within clinical practice and policy. It could be applied to contexts beyond mesothelioma, general practice, and the UK, and is potentially relevant to all patients seeking to achieve, and all healthcare professionals keen to deliver, continuity of care.

Introduction: Avoidable and unfair variation in access to palliative care exists for different groups of people and communities. Primary and community care teams deliver most palliative care and care to people at the end of life at home but the quality of care provided is variable. This is an under-researched area and receives little attention in service design and policy. This study will investigate the key contexts, resources and components required for an integrated approach to palliative care to deliver improved and more equitable outcomes for patients and carers. Methods and analysis: This mixed-methods study adopts a realist methodological approach, and comprises four work packages: A multi-perspective mixed-methods study to understand patient preferences and priorities in palliative care, prioritising recruitment of patients and family members/carers from areas of socioeconomic deprivation. Data collection will comprise: (1) qualitative interviews, (2) review of patient case notes and (3) a discrete choice experiment. Realist analysis will result in the development of theory based on the identification of the key contexts and underlying mechanisms required to achieve beneficial outcomes through an integrated approach to palliative care. A realist evaluation of existing integrated models of palliative care will involve theory-refining interviews and theory-consolidating focus groups with professionals working in three different service areas. Dynamic simulation modelling of the healthcare resources needed to deliver the proposed integrated approach, ensuring quality and equity. The theoretical and economic modelling will be tested out at two expert stakeholder workshops to determine the key enablers to implementation in practice. Patient and public involvement: The study design was informed by patient and public involvement (PPI) with 16 patients and members of the public from diverse and socioeconomically deprived communities for 12 months in a National Institute for Health and Care Research-funded palliative care partnership. PPI will be continuous throughout the study, prioritising inclusivity. Ethics and dissemination: Ethical approval was obtained from the East of Scotland Research Ethics Service Research Ethics Committee 2, on 20 August 2025 (IRAS ID: 354755) and Health Research Authority approval on 1 October 2025. The targeted dissemination strategy will include outputs and resources for key audiences including patients and families, professionals in primary care and specialist palliative care and service commissioners. The results will inform service delivery to reduce inequities and optimise the use of finite resources to maximise impact. Trial registration details: The study is registered with the ISRCTN UK Clinical Study Registry: https://www.isrctn.com/ISRCTN61092011 .

Background: Continuity in general practice has clear benefits but is difficult to achieve. Existing research has identified groups of individuals who may especially benefit from continuity, such as those with a terminal condition. Mesothelioma is an incurable disease caused by asbestos exposure and people with this diagnosis derive significant benefit from continuity. However, there is little research exploring continuity in general practice for these individuals. Aim: The aim of this study was to provide detailed understanding of experiences of continuity in UK general practice among people with mesothelioma, their close persons, and their healthcare professionals (HCPs); how they achieve this (or not); and how it affects their healthcare service use. Method: Qualitative data obtained from longitudinal interviews with people with mesothelioma, their close persons, and their HCPs was used to construct detailed case studies. Reflexive thematic analysis was undertaken. Five individuals participated in a patient and public involvement capacity. Results: Data from 54 interviews formed nine case studies. Findings are presented in relation to five overarching themes: 1) people with mesothelioma experience unique challenges in achieving continuity; 2) patient/close person capacity to facilitate continuity in general practice; 3) HCP capacity to facilitate continuity in general practice; 4) MDT approach differs from traditional family doctor model; and 5) ‘NHS general practice is broken’. Conclusion: This research deepens understanding of continuity in general practice for people with mesothelioma. Although this study focused on people with mesothelioma in the UK, it is relevant to other international patient populations, particularly those with other rare conditions or palliative care needs.

Background: Funding shortfalls persist for practices in the most deprived areas, despite capitation formula adjustments. Aim: To evaluate whether deprivation scores predicted practice payment trends between 2019 and 2024. Design and setting: Multivariable analysis was undertaken of English general practices (2018–2019 to 2023–2024), excluding practices with £500 per patient per year, using published data. Method: A quadratic mixed-effects model was fitted, using cluster-robust standard errors. The outcome was log-transformed average NHS practice payments per patient (net of deductions/reimbursements). The fixed effects were time (categorical), the Index of Multiple Deprivation (IMD) score (higher score indicates greater deprivation), and seven covariates (geographical, population, or organisational). The random effect was practices’ random intercepts. Results: Among 5726 included practices, median payments increased in nominal terms (8.6%) but decreased in real terms (–12.6% consumer price index [CPI] and –9.0% CPI for health). The IMD–payment trend relationship was curvilinear, peaking at IMD 49.8 (1.4% above mean deprivation, IMD 23.2), declining to 0.6% higher at IMD 70.0. More positive payment trends were associated with non-London regions, rurality, greater long-term conditions (LTCs) prevalence, and higher baseline payments; less positive trends were associated with more patients aged <16 years, larger lists, and personal medical services contracts. In interaction models, rurality increased whereas higher LTCs decreased IMD’s impact. Conclusion: Deprivation had a positive but diminishing association with payment trends as deprivation increased, moderated by geography and morbidity. Payment uplifts must match inflation. Funding formulas must better compensate for deprivation and morbidity, address the attenuated positive effect of deprivation in practices with more patients with LTCs, and minimise geographical inequalities.

Objectives: Continuity is associated with improved outcomes for patients, clinicians and health systems, yet remains difficult to achieve in contemporary primary care. This study introduces CAP Continuity , an empirically grounded, realist‐informed, explanatory theory that accounts for how continuity is generated or disrupted in context. CAP Continuity conceptualises continuity as emerging from the interaction of three domains—competence, attitude and provision. Methods: A realist evaluation examined continuity for people with mesothelioma in UK general practice. Nine longitudinal patient case studies were developed using longitudinal realist interviews with patients, their healthcare professionals ( n = 12) and close persons ( n = 9). Analysis involved reflexive thematic coding, development of Context–Mechanism–Outcome configurations and theory refinement informed by Burden of Treatment Theory and the Candidacy Framework. Results: CAP Continuity proposes that continuity depends on (1) competence—the capabilities of patients, close persons, and professionals to understand, navigate, coordinate, and engage with care; (2) attitude—the relational, moral, and motivational orientations that shape whether people prioritise continuity and (3) provision—the organisational and system‐level arrangements that enable or constrain continuity. Continuity is most likely when these domains align; misalignment explains why continuity breaks down even when individual relationships appear strong. Conclusions: CAP Continuity offers an explanatory structure that integrates existing definitions with attention to context, mechanisms and system conditions. Developed in the context of mesothelioma and UK general practice, the theory is transferable—subject to contextual fit—to other community‐based settings where multidisciplinary care, workload and system pressures shape the possibilities for continuity.

I am a clinical academic. Boundaries are hugely important. It does not come naturally to me to implement and maintain boundaries (as I’m sure is the case for many of my like-minded colleagues) but it is absolutely imperative to ensure survival. The weight of managing the components of clinical academia is heavy: it requires balancing, and accepting, the frequent conflict between the needs of individual patients and the ‘bigger picture’ of the healthcare system. I remind myself that I must also take into account the energy required at any given time in my roles as a mother of young children; a wife to a resplendent husband; a daughter; granddaughter; sister; friend; and neighbour. But it is not simple when clinical practice, research, and policy are interconnected like chewing gum stubbornly entangled in hair.

Background: Profound changes to English general practice aim to improve access to appointments, however, how these changes might affect patients’ confidence and trust in healthcare professionals is unknown. Aim: To determine whether appointments that were 1) face to face with any type of healthcare professional, or 2) with GPs in any mode, were associated with variations in confidence and trust in the professional last seen. Design and setting: A practice-level cross-sectional study of 6196 English general practices was conducted from 2023–2024, using published data. Method: In a weighted regression model, the outcome was patient-reported confidence and trust in healthcare professionals. The two variables of interest were the percentages of appointments with GPs in any mode or face to face any healthcare professional and the nine covariates were continuity, access, whether patients’ needs were met, the annual appointment rate, practice list size, NHS region, deprivation, and practice populations’ age and ethnicity. Results: In the model, higher confidence and trust was associated with higher percentages of patients seen by GPs in any mode or face to face any healthcare professional, also with increased continuity, appointment rates, percentages of patients having their needs met, percentages of patients aged >18 years, and percentages of White ethnicity. Confidence and trust was higher in all regions compared with London. Lower confidence and trust was associated with higher deprivation. There was no association with improved access or list size. Conclusion: This study cannot establish causation but does suggest that strategies to improve access that lower continuity, reduce the percentage of appointments that are with GPs, and increase remote consulting may lead to lower confidence and trust in healthcare professionals.

The book is structured in a logical way, and starts with an introduction to the ‘basic’ concepts of autism and ADHD from separate lenses. This section reflects ‘the evolution of medical understanding, diagnostic frameworks and societal attitudes.’ Sadiq busts common myths; details diagnostic criteria; acknowledges understanding gained from, and limitations of, the existing literature; and discusses the history of both conditions. After having provided the reader with a firm grasp of ADHD and autism in their own rights, Sadiq starts to introduce the complexity of the combination of both conditions, presenting the ‘shared and distinct features of autism and ADHD’, which he suggests ‘originate from separate yet intertwined pathways’. Understanding of this is said to be imperative if we are to develop better diagnostic criteria and individualised support for people with both ADHD and autism. Sadiq uses patient case studies to provide real-world examples of how these seemingly contradictory conditions often co-exist.

Social determinants powerfully affect mortality rates but can be improved by national policies to reduce inequalities and enable healthier lifestyles. Cross-government action involving education, transport, welfare, environment, housing, and public health sectors at local and national levels is essential to improving life expectancy. Within the healthcare system, general practice also has a worthwhile role to play. We aim to explore the mechanisms through which general practice contributes to improving longevity, and to discuss some of the implications.