Background Primary care is the main route to diagnosis for patients with prostate cancer, either following asymptomatic Prostate Specific Antigen (PSA) testing or investigating prostate-related symptoms. Whilst previous primary care studies suggest an association between symptoms and prostate cancer diagnosis, it remains unknown whether outcomes differ based on the presence or absence of symptoms. Aim To compare prostate cancer stage, grade, and mortality amongst symptomatic patients presenting to primary care with asymptomatic patients. Design and setting Retrospective cohort study using Clinical Practice Research Datalink (CPRD) Aurum. Included adult males aged 50 years and above with first presentation to primary care for coded lower urinary tract symptoms (LUTS), haematuria, or erectile dysfunction between 01/01/2011 and 31/12/2016 with up to two asymptomatic males matched by age, ethnicity, and GP practice. Method Main outcomes: Clinically significant prostate cancer (Gleason Grade Group ≥ 3); Early-stage prostate cancer; Cambridge Prognostic Group; prostate cancer mortality; all-cause mortality. Mixed effect logistic regression modelling was performed. Results 722,597 males were included (262,178 [36.3%] had coded symptoms). Mean age was 64.4 years (SD 9.76). 90.68% identified as White ethnicity. 12,297 new prostate cancer diagnoses within 24 months of index consultation (8,101 [65.88%] in symptomatic group). Clinically significant prostate cancer (Adjusted OR 1.14 95% CI 1.07, 1.23) was more likely in the symptomatic group. No difference was found in stage at diagnosis (aOR 1.02 95% CI 0.95,1.09). Conclusion Investigating symptomatic patients in primary care is more likely to detect clinically significant prostate cancer with no difference in stage at diagnosis.

Background 20% of general practices in the England have closed or merged since 2013. Little is known about factors that are associated with these closures, despite evidence on their negative impacts. Understanding these risks is important for recovering general practice. Aim Describe how differences in the patient mix, practice location, workforce, funding and quality are associated with the future risk of closure Design and Setting Multilevel survival analysis of all general practices in England. Method All practices open on 1st April 2019 were followed until 1st April 2025 or closure. We gathered data on practice population characteristics, workforce, funding and quality. Cox proportional hazards models were used to analyse how these measures were associated with time to closure. Results Practice contract type and geographic location (region and rurality) were key factors associated with closures or mergers. For example, rates ranged from 3.7% to 19.7% by geographic region. Greater risk was associated with smaller practices, with a practice at the 10th percentile (3,032 patients) having 253% (95% CrI: 200%, 312%) higher risk of closure or merger than the median (7,256 patients). Greater risk of closure or merger was associated with losing or failing to gain patients (hazard ratio v medium increase 1.68 (95%CrI: 1.44, 1.96), lower baseline funding, poorer clinical quality, higher socioeconomic deprivation and certain contract types, but not the supply of general practitioners or nurses. Conclusion The practice contract, relevant region, practice list size, funding and quality are key hazards for the subsequent closure or merger of general practices.

Background Where available, Advice and Guidance (A&G) can enable primary care clinicians to seek specialist input, supporting decision making and avoiding unnecessary referrals. The use of A&G has significantly expanded, accelerated by COVID19 and contractual changes. While A&G is intended to streamline elective care, concerns persist regarding workload shift, variable responsiveness, and system usability. Despite growing policy emphasis, little is known about why clinicians choose to use A&G. Aim Explore the current use of A&G within primary care, focusing on decision making processes which underpin PCCs' (primary care clinicians') decision to use A&G. Design and Setting Qualitative study set in English Primary Care Method Twenty semi structured video interviews were conducted with primary care clinicians purposively sampled for maximum variation. Data were analysed using reflexive thematic analysis within an interpretive description framework, with themes developed collaboratively and refined through discussion with researchers and PPIE contributors. Ethical approval was obtained (REC 333799). Results Four overarching themes encapsulate clinicians' decisions to use A&G: clinical presentation (acuity and complexity), navigating healthcare pathways, previous experiences of A&G, and using A&G to validate clinical decision making. Barriers included delayed responses and uncertainty about inequitable workload distribution. These factors shape how effectively A&G could be integrated into routine practice. Conclusion Primary care clinicians use A&G to support patient care and aid decision-making, but its effectiveness depends on timely, clinically helpful responses. Ensuring responses remain appropriate to primary care remit and capacity will be essential if A&G becomes the main route into elective care.

Background Demand on emergency healthcare services is increasing. Utilising GPs in emergency ambulance services (EAS) may be effective in reducing avoidable conveyances to emergency departments and releasing emergency ambulances for higher-acuity cases. There is limited evidence on models of GP EAS roles in the UK. Aims To describe current provision of GP EAS roles and to develop a provisional explanatory programme theory. Design & Setting Qualitative realist interview study with professionals with detailed knowledge and experience of GPs working in EAS. Method Interviews were conducted with 27 participants to explore the mechanisms by which GP EAS roles produce their intended outcomes in different contexts. Results The GP role is predominantly to undertake enhanced remote patient assessment following an initial algorithmic triage, aiming to provide the most appropriate level of care. Whilst optimising the clinical response to individual callers, this also serves a system-level function by protecting ambulance resources to support timely responses to high-acuity patients. The mechanism behind GP-triage was explored through existing middle-range theories around risk individualisation, the process of translating organisational risk appetite to individual patient contacts. This helps the ambulance service make 'braver' decisions; those involving non-conveyance, alternatives to conveyance, or lower-acuity responses. GPs do this effectively due to their seniority, broad clinical knowledge and experience, approach to risk and uncertainty, ability to practice outside guidelines, consultation and communication skills, and system awareness. Conclusion GPs in EAS serve both individual patients and the system by individualising organisational approaches to risk and resource management.

Background Timely diagnosis of cancer can be challenging as most present with non-specific symptoms in primary care. A third of those diagnosed with cancer report receiving a non-cancer diagnosis, before being referred for cancer investigations ('interim' diagnosis), presenting a potential missed diagnostic opportunity. Aim This study explored patients' experiences of receiving a non-cancer diagnosis prior to referral for investigation for suspected cancer. Design and Setting Secondary qualitative analysis of seven interview datasets collected in primary care in the UK since 2015. Method Patient journeys were summarised, charted and analysed using framework analysis. Patient Public Involvement and Engagement collaborators were involved throughout. Results 58 transcripts were included in which the patient presented to primary care with symptoms and received an interim non-cancer diagnosis. We identified eight common scenarios involving an initial non-cancer diagnosis followed by referral for suspected cancer. For example, individuals considered at low risk of cancer reported symptoms being linked to lifestyle factors, requiring multiple contacts over time before further investigation was considered. Patients queried interim diagnoses when they felt their symptoms and interpretations had been poorly understood, or they had been given inappropriate investigations or ineffective treatment. While patients recognised the difficulty of deciding when common symptoms required onward referral, they trusted clinicians who were responsive to their concerns, regardless of outcome. Conclusion Interim diagnoses arise as part of the normal diagnostic process in patients presenting with non-specific symptoms. Challenging these diagnoses in the face of new evidence could mitigate potential delays in diagnosis and improve patient outcomes.