Interventions targeted at primary care practitioners to improve the identification and referral of patients with co-morbid obesity: a realist review protocol

<b>Background </b>Obesity is one of the most significant public health challenges in the developed world. Recent policy has suggested that more can be done in primary care to support adults with obesity. In particular, general practitioners (GPs) and practice nurses (PNs) could improve the identification and referral of adults with obesity to appropriate weight management services. Previous interventions targeted at primary care practitioners in this area have had mixed results, suggesting a more complex interplay between patients, practitioners, and systems. The objectives of this review are (i) to identify the underlying ‘programme theory’ of interventions targeted at primary care practitioners to improve the identification and referral of adults with obesity and (ii) to explore how and why GPs and PNs identify and refer individuals with obesity, particularly in the context of weight-related co-morbidity. This protocol will explain the rationale for using a realist review approach and outline the key steps in this process. <p></p> <b>Methods</b> Realist review is a theory-led approach to knowledge synthesis that provides an explanatory analysis aimed at discerning what works, for whom, in what circumstances, how, and why. In this review, scoping interviews with key stakeholders involved in the planning and delivery of adult weight management services in Scotland helped to inform the identification of formal theories - from psychology, sociology, and implementation science - that will be tested as the review progresses. A comprehensive search strategy is described, including scope for iterative searching. Data analysis is outlined in three stages (describing context-mechanism-outcome configurations, exploring patterns in these configurations, and developing and testing middle-range theories, informed by the formal theories previously identified), culminating in the production of explanatory programme theory that considers individual, interpersonal, and institutional/systems-level components. <p></p> <b>Discussion </b>This is the first realist review that we are aware of looking at interventions targeted at primary care practitioners to improve the weight management of adults with obesity. Engagement with stakeholders at an early stage is a unique feature of realist review. This shapes the scope of the review, identification of candidate theories and dissemination strategies. The findings of this review will inform policy and future interventions. Systematic review registration PROSPERO CRD4201400939

Medical education in (and for) areas of socio-economic deprivation in the UK

No abstract available

Commentary: Supporting GP training in areas of socio-economic deprivation

No abstract available

The role of primary care in adult weight management: qualitative interviews with key stakeholders in weight management services

Background: Primary care has a key role to play in the prevention and management of obesity, but there remain barriers to engagement in weight management by primary care practitioners. The aim of this study was to explore the views of key stakeholders in adult weight management services on the role of primary care in adult weight management. Methods: Qualitative study involving semi-structured interviews with nine senior dietitians involved in NHS weight management from seven Scottish health boards. Transcripts were analysed using an inductive thematic approach. Results: A range of tensions were apparent within three key themes: weight management service issues, the role of primary care, and communication with primary care. For weight management services, these tensions were around funding, the management model of obesity, and how to configure access to services. For primary care, they were around what primary care should be doing, who should be doing it, and where this activity should fit within wider weight management policy. With regard to communication between weight management services and primary care, there were tensions related to the approach taken (locally adapted versus centralised), the message being communicated (weight loss versus wellbeing), and the response from practitioners (engagement versus resistance). Conclusions: Primary care can do more to support adult weight management, but this requires better engagement and communication with weight management services, to overcome the tensions highlighted in this study. This, in turn, requires more secure, sustained funding. The example of smoking cessation in the UK, where there is a network of well-resourced NHS Stop Smoking Services, accessible via different means, could be a model to follow

Patient and practice characteristics predicting attendance and completion at a specialist weight management service in the UK: a cross-sectional study

Objective: To determine the association between patient and referring practice characteristics and attendance and completion at a specialist health service weight management service (WMS). Design: Cross-sectional study. Setting: Regional specialist WMS located in the West of Scotland. Participants: 9677 adults with obesity referred between 2012 and 2014; 3250 attending service and 2252 completing. Primary and secondary outcome measures: Primary outcome measure was attendance at the WMS; secondary outcome was completion, defined as attending four or more sessions. Analysis: Multilevel binary logistic regression models constructed to determine the association between patient and practice characteristics and attendance and completion. Results: Approximately one-third of the 9677 obese adults referred attended at least one session (n=3250, 33.6%); only 2252 (23%) completed by attending four or more sessions. Practice referrals ranged from 1 to 257. Patient-level characteristics were strongest predictors of attendance; odds of attendance increased with age (OR 4.14, 95% CI 3.27 to 5.26 for adults aged 65+ compared with those aged 18–24), body mass index (BMI) category (OR 1.83, 95% CI 1.56 to 2.15 for BMI 45+ compared with BMI 30–35) and increasing affluence (OR 1.96, 95% CI 1.17 to 3.28). Practice-level characteristics most strongly associated with attendance were being a non-training practice, having a larger list size and not being located in the most deprived areas. Conclusions: There was wide variation in referral rates across general practice, suggesting that there is still much to do to improve engagement with weight management by primary care practitioners. The high attrition rate from referral to attendance and from attendance to completion suggests ongoing barriers for patients, particularly those from the most socioeconomically deprived areas. Patient and practice-level characteristics can help us understand the observed variation in attendance at specialist WMS following general practitioner (GP) referral and the underlying explanations for these differences merit further investigation

'Learning together': Sharing international experience on new models of primary care

No abstract available

Addressing food insecurity - what is the role of healthcare?

No abstract available

The influence of socioeconomic deprivation on multimorbidity at different ages: a cross-sectional study

<b>Background</b> Multimorbidity occurs at a younger age in individuals in areas of high socioeconomic deprivation but little is known about the 'typology' of multimorbidity in different age groups and its association with socioeconomic status.<p></p> <b>Aim</b> To characterise multimorbidity type and most common conditions in a large nationally representative primary care dataset in terms of age and deprivation.<p></p> <b>Design and setting</b> Cross-sectional analysis of 1 272 685 adults in Scotland.<p></p> <b>Method</b> Multimorbidity type of participants (physical-only, mental-only, mixed physical, and mental) and most common conditions were analysed according to age and deprivation.<p></p> <b>Results</b> Multimorbidity increased with age, ranging from 8.1% in those aged 25–34 to 76.1% for those aged ≥75 years. Physical-only (56% of all multimorbidity) was the most common type of multimorbidity in those aged ≥55 years, and did not vary substantially with deprivation. Mental-only was uncommon (4% of all multimorbidity), whereas mixed physical and mental (40% of all multimorbidity) was the most common type of multimorbidity in those aged <55 years and was two- to threefold more common in the most deprived compared with the least deprived in most age groups. Ten conditions (seven physical and three mental) accounted for the top five most common conditions in people with multimorbidity in all age groups. Depression and pain featured in the top five conditions across all age groups. Deprivation was associated with a higher prevalence of depression, drugs misuse, anxiety, dyspepsia, pain, coronary heart disease, and diabetes in multimorbid patients at different ages.<p></p> <b>Conclusion</b> Mixed physical and mental multimorbidity is common across the life-span and is exacerbated by deprivation from early adulthood onwards

The Deep End GP Pioneer Scheme: a qualitative evaluation

Background: The Scottish Deep End Project is a collaboration between academic GPs and GPs in practices serving the most socio-economically disadvantaged populations in Scotland. The Deep End GP Pioneer Scheme was established in 2016 to improve GP recruitment and retention in these areas. The aim of this study was to qualitatively evaluate the experiences of participating lead GPs and GP fellows. Methods: Semi-structured interviews were conducted with nine lead GPs and 10 GP fellows, representing 12 of the 14 practices involved. Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Results: Five main themes are presented: Recruitment to the Pioneer Scheme; Work motivation and satisfaction; Mitigating health inequalities; Retention and changes in work pattern; and Suggestions for the future. Key ingredients of the scheme were the additional clinical capacity (addressing the inverse care law), protected time for both GP fellows and experienced GPs to lead on service development initiatives and to share learning within and between practices, and the shared ethos and values of the Scheme. Conclusions: There was strong support for the Scheme as a mechanism to improve GP recruitment and retention in areas of high socio-economic disadvantage, and to improve quality of care in these areas. As similar schemes are rolled out across the UK, there is a need for further research to evaluate their impact on workforce and patient outcomes in deprived areas