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Background Communication between patients and staff is a crucial component of safe and effective healthcare. As people age, they have more consultations and these become more complex. As such, older people may be more likely to experience gaps and breakdowns in communication. Objective To develop a better understanding of older people's communication in interactions with primary care staff and the barriers to and enablers of this. Search Strategy Four databases were searched. Search terms covered the sample (older people), domain (verbal communication in healthcare interactions), context (primary care) and research type (qualitative research). Data Extraction and Synthesis A meta‐ethnographic approach was followed by one researcher, with input from the wider team. Twelve studies were included. Details of the designs, participants, methods and results were extracted. Data were synthesised through reciprocal translation, and a line of argument was developed. Main Results Barriers to communication were found in relation to raising and addressing concerns. Barriers arose from patient perceptions of their role, the nature of their relationship with staff, patient and staff perceptions of responsibility and reluctance to broach a topic, individual factors such as memory, how staff respond when concerns are raised and the degree of patient involvement in consultations. Potential enablers of communication were preparation and support from family or peers. Conclusions Synthesising the existing qualitative literature on older people's communication in healthcare interactions enabled the identification of barriers and enablers that can be used to inform the development of an intervention to improve communication with primary care staff. Patient or Public Contribution By identifying healthcare communication as the most important topic for the patient safety of older people with multiple long‐term conditions in primary care and setting the scope of the review, patients and the public were involved in the design of the study. Four public contributors (older people with multiple long‐term conditions and carers of older people with multiple long‐term conditions) attended regular meetings, provided their reflections on the study findings and supported the interpretation of the data.

Chronic kidney disease (CKD) is a global public health problem with major human and economic consequences. Despite advances in clinical guidelines, classification systems and evidence-based treatments, CKD remains underdiagnosed and undertreated and is predicted to be the fifth leading cause of death globally by 2040. This review aims to identify barriers and enablers to the effective detection, diagnosis, disclosure and management of CKD since the introduction of the Kidney Disease Outcomes Quality Initiative (KDOQI) classification in 2002, advocating for a renewed approach in response to updated Kidney Disease: Improving Global Outcomes (KDIGO) 2024 clinical guidelines. The last two decades of improvements in CKD care in the UK are underpinned by international adoption of the KDIGO classification system, mixed adoption of evidence-based treatments and research informed clinical guidelines and policy. Interpretation of evidence within clinical and academic communities has stimulated significant debate of how best to implement such evidence which has frequently fuelled and frustratingly forestalled progress in CKD care. Key enablers of effective CKD care include clinical classification systems (KDIGO), evidence-based treatments, electronic health record tools, financially incentivised care, medical education and policy changes. Barriers to effective CKD care are extensive; key barriers include clinician concerns regarding overdiagnosis, a lack of financially incentivised care in primary care, complex clinical guidelines, managing CKD in the context of multimorbidity, bureaucratic burden in primary care, underutilisation of sodium-glucose co-transporter-2 inhibitor (SGLT2i) medications, insufficient medical education in CKD, and most recently – a sustained disruption to routine CKD care during and after the COVID-19 pandemic. Future CKD care in UK primary care must be informed by lessons of the last two decades. Making step change, over incremental improvements in CKD care at scale requires a renewed approach that addresses key barriers to detection, diagnosis, disclosure and management across traditional boundaries of healthcare, social care, and public health. Improved coding accuracy in primary care, increased use of SGLT2i medications, and risk-based care offer promising, cost-effective avenues to improve patient and population-level kidney health. Financial incentives generally improve achievement of care quality indicators – a review of financial and non-financial incentives in CKD care is urgently needed.

Patients with biochemical evidence of chronic kidney disease (CKD) without a diagnostic code (uncoded CKD) in primary care are at increased risk of death, acute kidney injury (AKI), and unplanned hospital care. Uncoded CKD is highly prevalent and there is no data to evaluate whether patients with uncoded CKD were at an increased risk of COVID-19 death. Aim: to assess whether patients with uncoded CKD stages 3-5 were at increased risk of death and COVID-19 deaths. Descriptive and inferential analyses to measure adjusted hazard of death, and COVID-19 death in patients with CKD stages 3-5 from 2.85 million primary care patients in Greater Manchester, England. Sensitivity analyses using propensity score matching and competing risk regression. Coded CKD stages 3 and 4 (versus uncoded) were associated with significantly lower adjusted hazards of death (HR 0.81, CIs 0.77-0.86, p=<0.0001; HR 0.45, CIs 0.34-0.60, p=<0.0001, respectively), and COVID-19 death (HR 0.74, CIs 0.55-0.99, p = 0.03; HR 0.55, CIs 0.30-0.99, p = 0.045, respectively). Descriptive analyses were conducted for patients with CKD stage 5 due to low numbers of patients with uncoded CKD stage 5, precluding survival analyses. Our retrospective cohort study suggests that clinical coding is a digital intervention associated with a lower adjusted hazard of death and COVID-19 death in patients with CKD stages 3 and 4, and should be considered a key element in the organisation and delivery of care for people with CKD.

Background Chronic kidney disease (CKD) is a growing global health concern requiring effective self-management to mitigate progression and improve quality of life. While self-management is increasingly recognised as a socially embedded practice, the specific contributions of social network members to this process in CKD are not well understood. Objective To synthesise and interpret existing literature on how social networks support individuals living with early-stage CKD and identify gaps in understanding. Methods We conducted a narrative review. Fourteen studies involving 560 participants—including individuals living with CKD, their social network members, healthcare professionals, peer mentors, and religious leaders—were analysed to explore the role of social networks in CKD self-management. Results Four key themes emerged: (1) The burden of kidney disease uncertainty (2), Everyday challenges of managing CKD (3), The loneliest disease , and (4) The role of peer support . Participants frequently reported emotional distress linked to diagnostic uncertainty and inconsistent information, especially from non-specialist providers. CKD management posed significant practical and psychological burdens, particularly for caregivers, who often felt unsupported and invisible within healthcare systems. Peer support—both informal and formal—played a crucial role in reducing isolation and providing context-specific guidance, especially when tailored to individual preferences and illness trajectories. Conclusions This is the first review to explore the role of social networks in supporting the self-management of people living with CKD. The studies highlighted that early-stage CKD is shaped by diagnostic uncertainty, limited formal support, and social invisibility. People with CKD rely on diverse social networks for self-management, yet unclear care pathways and inconsistent communication hinder this support. Integrated models that combine early specialist input, peer support, and trained generalists are needed. Recognising and supporting these networks is essential to reduce isolation, improve understanding, and enable meaningful engagement with self-management across the CKD trajectory.

Poor communication is a key causal factor of medication safety incidents. Collaboration between community pharmacy (CP) and general practice (GP) staff is essential but hindered by multiple barriers. This study applied an Experience-Based Co-Design (EBCD) approach, incorporating Systems Thinking for Everyday Work (STEW), to develop interventions for improving collaboration and communication on medication safety across the GP-CP interface. A sequential study design was undertaken, including: 1) an experience gathering phase to understand the communication of medication safety issues across the GP-CP interface, involving online focus groups and interviews with 27 GP and CP staff; and 2) two online EBCD workshops with 21 participants, including patients and primary care staff, to generate and prioritise interventions for improving medication safety communication and collaboration. Focus groups, interviews and workshops were audio-recorded, transcribed, and thematically analysed. Three key touchpoints for communication and collaboration on medication safety issues were identified: medication errors, medication changes, and potential patient safety concerns. An absence of shared communication approaches and the prioritisation of medication safety issues, one way communication tools, lack of understanding of professional roles and of incident reporting processes were barriers to communication and collaboration. Facilitators included GP pharmacist-community pharmacist relationships, face-to-face interactions and staff continuity. Five key interventions were suggested: development/modification of an electronic two-way communication tool between GP and CP; centralisation and sharing of patient records; interprofessional education; co-location of general practices and community pharmacies; and a toolkit for improving medication safety across the GP-CP interface. Participants agreed that a toolkit to address key communication and collaboration issues arising at multiple touchpoints should be prioritised for development and discussions led to refinement of ideas and production of a toolkit blueprint. Further research is required to refine toolkit resources, establish an implementation pathway, and evaluate its effectiveness to support adoption and improvements in medication safety.

Implementation of self-management support in traditional primary care settings has proved difficult, encouraging the development of alternative models which actively link to community resources. Chronic kidney disease (CKD) is a common condition usually diagnosed in the presence of other co-morbidities. This trial aimed to determine the effectiveness of an intervention to provide information and telephone-guided access to community support versus usual care for patients with stage 3 CKD. In a pragmatic, two-arm, patient level randomised controlled trial 436 patients with a diagnosis of stage 3 CKD were recruited from 24 general practices in Greater Manchester. Patients were randomised to intervention (215) or usual care (221). Primary outcome measures were health related quality of life (EQ-5D health questionnaire), blood pressure control, and positive and active engagement in life (heiQ) at 6 months. At 6 months, mean health related quality of life was significantly higher for the intervention group (adjusted mean difference = 0.05; 95% CI = 0.01, 0.08) and blood pressure was controlled for a significantly greater proportion of patients in the intervention group (adjusted odds-ratio = 1.85; 95% CI = 1.25, 2.72). Patients did not differ significantly in positive and active engagement in life. The intervention group reported a reduction in costs compared with control. An intervention to provide tailored information and telephone-guided access to community resources was associated with modest but significant improvements in health related quality of life and better maintenance of blood pressure control for patients with stage 3 CKD compared with usual care. However, further research is required to identify the mechanisms of action of the intervention. Controlled-Trials.com ISRCTN45433299.

Background Despite high level of health care need amongst people experiencing homelessness, poor access is a major concern. This is sometimes due to organisational and bureaucratic barriers, but also because they often feel stigmatised and treated badly when they do seek health care. The COVID-19 pandemic and the required social distancing measures have caused unprecedented disruption and change for the organisation of primary care, particularly for people experiencing homelessness. Against this backdrop there are many questions to address regarding whether the recent changes required to deliver services to people experiencing homelessness in the context of COVID-19 will help to address or compound problems in accessing care and inequalities in health outcomes. Methods An action led and participatory research methodology will be employed to address the study objectives. Interviews with people experiencing homelessness were will be conducted by a researcher with lived experience of homelessness. Researchers with lived experience are able to engage with vulnerable communities in an empathetic, non-judgemental way as their shared experience promotes a sense of trust and integrity, which in turn encourages participation in research and may help people speak more openly about their experience. The experiences of health professionals and stakeholders delivering and facilitating care for people experiencing homelessness during the pandemic will also be explored. Discussion It is important to explore whether recent changes to the delivery of primary care in response to the COVID-19 pandemic compromise the safety of people experiencing homelessness and exacerbate health inequalities. This could have implications for how primary healthcare is delivered to those experiencing homelessness not only for the duration of the pandemic but in the future.

IntroductionPatients being discharged from inpatient mental wards often describe safety risks in terms of inadequate information sharing and involvement in discharge decisions. Through stakeholder engagement, we co-designed, developed and adapted two versions of a care bundle intervention, the SAFER Mental Health care bundle for adult and youth inpatient mental health settings (SAFER-MH and SAFER-YMH, respectively), that look to address these concerns through the introduction of new or improved processes of care.Methods and analysisTwo uncontrolled before-and-after feasibility studies, where all participants will receive the intervention. We will examine the feasibility and acceptability of the SAFER-MH in inpatient mental health settings in patients aged 18 years or older who are being discharged and the feasibility and acceptability of the SAFER-YMH intervention in inpatient mental health settings in patients aged between 14 and 18 years who are being discharged. The baseline period and intervention periods are both 6 weeks. SAFER-MH will be implemented in three wards and SAFER-YMH in one or two wards, ideally across different trusts within England. We will use quantitative (eg, questionnaires, completion forms) and qualitative (eg, interviews, process evaluation) methods to assess the acceptability and feasibility of the two versions of the intervention. The findings will inform whether a main effectiveness trial is feasible and, if so, how it should be designed, and how many patients/wards should be included.Ethics and disseminationEthical approval was obtained from the National Health Service Cornwall and Plymouth Research Ethics Committee and Surrey Research Ethics Committee (reference: 22/SW/0096 and 22/LO/0404). Research findings will be disseminated with participating sites and shared in various ways to engage different audiences. We will present findings at international and national conferences, and publish in open-access, peer-reviewed journals.

ObjectivesSince 2006, general practitioners (GPs) in England, UK, have been incentivised to keep a register and monitor patients with chronic kidney disease (CKD) stages 3–5. Despite tensions and debate around the merit of this activity, there has been little qualitative research exploring clinician perspectives on monitoring early-stage CKD in primary care. This study aimed to examine and understand a range of different healthcare professional views and experiences of identification and monitoring in primary care of early-stage CKD, in particular stage 3.DesignQualitative design using semistructured interviews.SettingNational Health Service (NHS) settings across primary and secondary care in South West England, UK.Participants25 clinicians: 16 GPs, 3 practice nurses, 4 renal consultants and 2 public health physicians.ResultsWe identified two related overarching themes of dissonance and consonance in clinician perspectives on early-stage CKD monitoring in primary care. Clinician dissonance around clinical guidelines for CKD monitoring emanated from different interpretations of CKD and different philosophies of healthcare and moral decision-making. Clinician consonance centred on the need for greater understanding of renal decline and increasing proteinuria testing to reduce overdiagnosis and identify those patients who were at risk of progression and further morbidity and who would benefit from early intervention. Clinicians recommended adopting a holistic approach for patients with CKD representing a barometer of overall health.ConclusionsThe introduction of new National Institute for Health and Care Excellence (NICE) CKD guidelines in 2014, which focus the meaning and purpose of CKD monitoring by increased proteinuria testing and assessment of risk, may help to resolve some of the ethical and moral tensions clinicians expressed regarding the overmedicalisation of patients with a CKD diagnosis.

BackgroundOver the past decade, targeting acute kidney injury (AKI) has become a priority to improve patient safety and health outcomes. Illness complicated by AKI is common and is associated with adverse outcomes including high rates of unplanned hospital readmission. Through national patient safety directives, NHS England has mandated the implementation of an AKI clinical decision support system in hospitals. In order to improve care following AKI, hospitals have also been incentivised to improve discharge summaries and general practices are recommended to establish registers of people who have had an episode of illness complicated by AKI. However, to date, there is limited evidence surrounding the development and impact of interventions following AKI.DesignWe conducted a quality improvement project in primary care aiming to improve the management of patients following an episode of hospital care complicated by AKI. All 31 general practices within a single NHS Clinical Commissioning Group were incentivised by a locally commissioned service to engage in audit and feedback, education training and to develop an action plan at each practice to improve management of AKI.ResultsAKI coding in general practice increased from 28% of cases in 2015/2016 to 50% in 2017/2018. Coding of AKI was associated with significant improvements in downstream patient management in terms of conducting a medication review within 1 month of hospital discharge, monitoring kidney function within 3 months and providing written information about AKI to patients. However, there was no effect on unplanned hospitalisation and mortality.ConclusionThe findings suggest that the quality improvement intervention successfully engaged a primary care workforce in AKI-related care, but that a higher intensity intervention is likely to be required to improve health outcomes. Development of a real-time audit tool is necessary to better understand and minimise the impact of the high mortality rate following AKI.