The BARCODE1 Pilot: a feasibility study of using germline single nucleotide polymorphisms to target prostate cancer screening.

OBJECTIVES: To assess the feasibility and uptake of a community-based prostate cancer (PCa) screening programme selecting men according to their genetic risk of PCa. To assess the uptake of PCa screening investigations by men invited for screening. The uptake of the pilot study would guide the opening of the larger BARCODE1 study recruiting 5000 men. SUBJECTS AND METHODS: Healthy males aged 55-69 years were invited to participate via their general practitioners (GPs). Saliva samples were collected via mailed collection kits. After DNA extraction, genotyping was conducted using a study specific assay. Genetic risk was based on genotyping 130 germline PCa risk single nucleotide polymorphisms (SNPs). A polygenic risk score (PRS) was calculated for each participant using the sum of weighted alleles for 130 SNPs. Study participants with a PRS lying above the 90th centile value were invited for PCa screening by prostate magnetic resonance imaging (MRI) and biopsy. RESULTS: Invitation letters were sent to 1434 men. The overall study uptake was 26% (375/1436) and 87% of responders were eligible for study entry. DNA genotyping data were available for 297 men and 25 were invited for screening. After exclusions due to medical comorbidity/invitations declined, 18 of 25 men (72%) underwent MRI and biopsy of the prostate. There were seven diagnoses of PCa (38.9%). All cancers were low-risk and were managed with active surveillance. CONCLUSION: The BARCODE1 Pilot has shown this community study in the UK to be feasible, with an overall uptake of 26%. The main BARCODE1 study is now open and will recruit 5000 men. The results of BARCODE1 will be important in defining the role of genetic profiling in targeted PCa population screening. Patient Summary What is the paper about? Very few prostate cancer screening programmes currently exist anywhere in the world. Our pilot study investigated if men in the UK would find it acceptable to have a genetic test based on a saliva sample to examine their risk of prostate cancer development. This test would guide whether men are offered prostate cancer screening tests. What does it mean for patients? We found that the study design was acceptable: 26% of men invited to take part agreed to have the test. The majority of men who were found to have an increased genetic risk of prostate cancer underwent further tests offered (prostate MRI scan and biopsy). We have now expanded the study to enrol 5000 men. The BARCODE1 study will be important in examining whether this approach could be used for large-scale population prostate cancer screening.

Videoconferencing to deliver genetics services: a systematic review of telegenetics in light of the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic has forced reorganization of clinical services to minimize face-to-face contact between patients and health-care providers. Specialist services, including clinical genetics, must consider methods of remote delivery including videoconferencing-termed telegenetics. This review evaluates the evidence for telegenetics and its applicability to future service development. METHODS: A systematic review of six databases was conducted to identify studies from 2005 onward using synchronous videoconferencing to deliver clinical genetics services. Included studies compared telegenetics to an alternative method or used a before and after design. RESULTS: Thirteen studies met the inclusion criteria (eight compared telegenetics to in-person consultations and three to telephone delivery). Patient satisfaction, genetic knowledge, and psychosocial outcomes were similar for in-person and telegenetic counseling. There was some evidence that telegenetics may be superior to telephone delivery for knowledge gain and reduction in anxiety and depression. There is limited evidence concerning the effect of telegenetics on provider satisfaction and behavioral outcomes. Conclusions are limited by at least moderate risk of bias in all evaluated studies and small sample sizes. CONCLUSION: Across most outcomes measured, telegenetics had equivalent outcomes to in-person appointment; however, the extent to which the available evidence is applicable to longer-term use is debatable.

Defining dimensions of research readiness: a conceptual model for primary care research networks.

BACKGROUND: Recruitment to research studies in primary care is challenging despite widespread implementation of electronic patient record (EPR) systems which potentially make it easier to identify eligible cases. METHODS: Literature review and applying the learning from a European research readiness assessment tool, the TRANSFoRm International Research Readiness instrument (TIRRE), to the context of the English NHS in order to develop a model to assess a practice's research readiness. RESULTS: Seven dimensions of research readiness were identified: (1) Data readiness: Is there good data quality in EPR systems; (2) Record readiness: Are EPR data able to identify eligible cases and other study data; (3) Organisational readiness: Are the health system and socio-cultural environment supportive; (4) Governance readiness: Does the study meet legal and local health system regulatory compliance; (5) Study-specific readiness; (6) Business process readiness: Are business processes tilted in favour of participation: including capacity and capability to take on extra work, financial incentives as well as intangibles such as social and intellectual capital; (7) Patient readiness: Are systems in place to recruit patients and obtain informed consent? CONCLUSIONS: The model might enable the development of interventions to increase participation in primary care-based research and become a tool to measure the progress of practice networks towards the most advanced state of readiness.

Implementing a digital rare disease case-finding tool in UK primary care: a qualitative study of health professionals' experience.

BACKGROUND: Rare diseases affect millions of people globally, with a lifetime incidence of 1 in 17. They are complex, multisystem, severe disease, and patients experience a diagnostic delay averaging 5.6 years with associated misdiagnoses, inappropriate treatments, and anxiety. MendelScan is a digital case-finding tool that uses structured primary care data to identify patients at risk of being affected by one of a series of rare diseases. This qualitative study explored primary healthcare professionals' experiences of implementing this technology. AIM: To develop an understanding of primary healthcare professionals' experiences of implementing MendelScan with a focus on their perception of the technology and its implementation, challenges and opportunities. METHOD: A qualitative appraisal of implementing MendelScan using descriptive analysis of surveys and semi-structured interviews with professionals. RESULTS: A total of 11 professionals from the two project areas participated. Participants included GPs, nurses, a genetic counsellor, and healthcare managers.Participants reported that they received adequate support, the project increased confidence in integrating genetics in primary care, and that it may improve inequity in rare disease diagnosis. Professionals' reservations were related to knowledge, time commitments, primary care pressures, contacting patients, data sharing and confidentiality, and overcoming clinical resistance in sharing data with a non-NHS external body. CONCLUSION: This study provides a valuable insight into the experiences of primary care professionals using a novel tool to identify rare diseases. The potential of this tool is promising with benefits for skill development. Large-scale implementation faces challenges related to primary care capacity, data, and funding.

Audit-based education lowers systolic blood pressure in chronic kidney disease: the Quality Improvement in CKD (QICKD) trial results.

Strict control of systolic blood pressure is known to slow progression of chronic kidney disease (CKD). Here we compared audit-based education (ABE) to guidelines and prompts or usual practice in lowering systolic blood pressure in people with CKD. This 2-year cluster randomized trial included 93 volunteer general practices randomized into three arms with 30 ABE practices, 32 with guidelines and prompts, and 31 usual practices. An intervention effect on the primary outcome, systolic blood pressure, was calculated using a multilevel model to predict changes after the intervention. The prevalence of CKD was 7.29% (41,183 of 565,016 patients) with all cardiovascular comorbidities more common in those with CKD. Our models showed that the systolic blood pressure was significantly lowered by 2.41 mm Hg (CI 0.59-4.29 mm Hg), in the ABE practices with an odds ratio of achieving at least a 5 mm Hg reduction in systolic blood pressure of 1.24 (CI 1.05-1.45). Practices exposed to guidelines and prompts produced no significant change compared to usual practice. Male gender, ABE, ischemic heart disease, and congestive heart failure were independently associated with a greater lowering of systolic blood pressure but the converse applied to hypertension and age over 75 years. There were no reports of harm. Thus, individuals receiving ABE are more likely to achieve a lower blood pressure than those receiving only usual practice. The findings should be interpreted with caution due to the wide confidence intervals.

Improving the management of people with a family history of breast cancer in primary care: before and after study of audit-based education.

BACKGROUND: In England, guidance from National Institute for Clinical Excellence (NICE) states women with a family history of breast cancer presenting to primary care should be reassured or referred.We reviewed the evidence for interventions that might be applied in primary care and conducted an audit of whether low risk women are correctly advised and flagged. METHODS: We conducted a literature review to identify modifiable risk factors. We extracted routinely collected data from the computerised medical record systems of 6 general practices (population approximately 30,000); of the variables identified in the guidance. We implemented a quality improvement (QI) intervention called audit-based education (ABE) comparing participant practices with guidelines and each other before and after; we report odds ratios (OR) of any change in data recording. RESULTS: The review revealed evidence for advising on: diet, weight control, physical exercise, and alcohol. The proportion of patients with recordings of family history of: disease, neoplasms, and breast cancer were: 39.3%, 5.1% and 1.3% respectively. There was no significant change in the recording of family history of disease or cancer; OR 1.02 (95% CI 0.98-1.06); and 1.08 (95% CI 0.99-1.17) respectively. Recording of alcohol consumption and smoking both increased significantly; OR 1.36 (95% CI 1.30-1.43); and 1.42 (95% CI 1.27-1.60) respectively. Recording lifestyle advice fell; OR 0.84 (95% CI 0.81-0.88). CONCLUSIONS: The study informs about current data recording and willingness to engage in ABE. Recording of risk factors improved after the intervention. Further QI is needed to achieve adherence to current guidance.

Identifying current training provision and future training needs in allergy available for UK general practice trainees: national cross-sectional survey of General Practitioner Specialist Training programme directors.

BACKGROUND: There are ongoing concerns about the quality of care provision for allergy in primary care. AIMS: To identify current training provision in allergy to GP trainees and to understand how this could be enhanced. METHODS: A cross-sectional survey of GP Speciality Training (GPST) programme directors was undertaken. Programme directors of the 174 GPST schemes were sent an online questionnaire which was informed by the content of the Royal College of General Practitioners curriculum. Quantitative data were descriptively analysed and a thematic analysis was undertaken of free text responses. RESULTS: We obtained responses from 146 directors representing 106 training programmes. Responses indicated that two-thirds (62%, 95% CI 53.1 to 71.5) of programmes were providing at least some allergy training, with the remaining third stating that they either provided no training or were unsure. Overall, one-third (33%, 95% CI 22.7 to 42.2) of programme directors believed that all the relevant allergy-related curriculum requirements were being met. Where provided, this training was believed to be best for organ-specific allergic disorders but was thought to be poorer for systemic allergic disorders, particularly food allergy where 67% (95% CI 57.5 to 76.5) of respondents indicated that training was poor. There was considerable interest in increasing the allergy training provided, preferably through eLearning modules and problem-based learning materials supported by those with relevant specialist knowledge. CONCLUSIONS: This UK-wide survey has identified important gaps in the training of GP trainees in relation to allergy care. Addressing these gaps, particularly in the management of systemic allergic disorders, should help to improve delivery of primary care-based allergy care.

Embedding genomics across the NHS: a primary care perspective.

Primary care remains the point of access to the NHS as well as having key roles in care coordination and prescribing. Therefore, embedding of genomic medicine in the NHS relies on successful implementation into the primary care landscape. Primary care is currently facing considerable challenges, including increasing numbers of patients and consultations per GP, multiple health conditions and polypharmacy, all contributing to increasing workload within a resource-constrained system. Although genomic medicine has enormous potential to benefit patients, its successful implementation demands alignment with existing skills and working practices, development of underpinning informatics infrastructure, integration into care pathways with consideration of commissioning and leadership. Here, we set out current initiatives and future strategies to support primary care colleagues in the delivery of genomic medicine, covering issues of workforce development and education, primary care leadership, and data and digital considerations.

Integrating primary care: an inside perspective on the Fuller Stocktake.

In November 2021 Claire Fuller led a national piece of work looking at primary care within integrated care systems (ICSs) to identify what was working well and why. The published report from this piece of work became known as the Fuller Stocktake.1 In this interview, Professor Fuller sets out the process and principles behind the Stocktake.

Impact of General Practitioner Education on Acceptance of an Adjuvanted Seasonal Influenza Vaccine among Older Adults in England.

Seasonal vaccination against influenza and in-pandemic COVID-19 vaccination are top public health priorities; vaccines are the primary means of reducing infections and also controlling pressures on health systems. During the 2018-2019 influenza season, we conducted a study of the knowledge, attitudes, and behaviours of 159 general practitioners (GPs) and 189 patients aged ≥65 years in England using a combination of qualitative and quantitative approaches to document beliefs about seasonal influenza and seasonal influenza vaccine. GPs were surveyed before and after a continuing medical education (CME) module on influenza disease and vaccination with an adjuvanted trivalent influenza vaccine (aTIV) designed for patients aged ≥65 years, and patients were surveyed before and after a routine visit with a GP who participated in the CME portion of the study. The CME course was associated with significantly increased GP confidence in their ability to address patients' questions and concerns about influenza disease and vaccination (p < 0.001). Patients reported significantly increased confidence in the effectiveness and safety of aTIV after meeting their GP. Overall, 82.2% of the study population were vaccinated against influenza (including 137 patients vaccinated during the GP visit and 15 patients who had been previously vaccinated), a rate higher than the English national average vaccine uptake of 72.0% that season. These findings support the value of GP-patient interactions to foster vaccine acceptance.

The provision and impact of online patient access to their electronic health records (EHR) and transactional services on the quality and safety of health care: systematic review protocol.

BACKGROUND: Innovators have piloted improvements in communication, changed patterns of practice and patient empowerment from online access to electronic health records (EHR). International studies of online services, such as prescription ordering, online appointment booking and secure communications with primary care, show good uptake of email consultations, accessing test results and booking appointments; when technologies and business process are in place. Online access and transactional services are due to be rolled out across England by 2015; this review seeks to explore the impact of online access to health records and other online services on the quality and safety of primary health care. OBJECTIVE: To assess the factors that may affect the provision of online patient access to their EHR and transactional services, and the impact of such access on the quality and safety of health care. METHOD: Two reviewers independently searched 11 international databases during the period 1999-2012. A range of papers including descriptive studies using qualitative or quantitative methods, hypothesis-testing studies and systematic reviews were included. A detailed eligibility criterion will be used to shape study inclusion. A team of experts will review these papers for eligibility, extract data using a customised extraction form and use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) instrument to determine the quality of the evidence and the strengths of any recommendation. Data will then be descriptively summarised and thematically synthesised. Where feasible, we will perform a quantitative meta-analysis. Prospero (International Prospective Register of Systematic Reviews) registration number: crd42012003091.

Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: prepared on behalf of the British Committee for Standards in Haematology by a working party of the Haemato-Oncology task force.

Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were first published by the British Committee for Standards in Haematology (BCSH) in 1996 and formally reviewed in 2002. Although the guidelines originated from discussion within the BCSH, the intended readership is wide given the multidisciplinary nature of the management of hyposplenism.

Experiences of GP trainees in undertaking telephone consultations: a mixed-methods study.

BACKGROUND: Primary care telephone consultations are increasingly used for patient triage, reviews, and providing clinical information. They are also a key postgraduate training component yet little is known about GP trainees' preparation for, or experiences and perceptions of, them. AIM: To understand the experiences, perceptions, and training of GP trainees in conducting telephone consultations. DESIGN & SETTING: A mixed-methods study was undertaken of North Central and East London (NCEL) GP trainees. METHOD: A cross-sectional electronic survey of trainees was performed with subsequent semi-structured interviews. Survey data were analysed using descriptive statistics, and qualitative data using thematic analysis. RESULTS: The survey response was 16% (n = 100/618), and 10 participated in semi-structured interviews. Trainees felt least confident with complicated telephone consulting, and there was a strong positive correlation between the percentage reporting having received training and their confidence (R 2 = 0.71, P<0.0001). Positive experiences included managing workload and convenience. Negative experiences included complex encounters, communication barriers, and absence of examination. Trainees reported that training for telephone consultations needed strengthening, and that recently introduced audio-clinical observation tools (COTs) were useful. Positive correlations were found between the length of out-of-hours (OOH) but not in-hours training and the level of supervision or feedback received for telephone consultations. CONCLUSION: This project sheds light on GP trainees' current experiences of telephone consultations and the need to enhance future training. The findings will inform a wider debate among stakeholders and postgraduate learners regarding training for telephone consultations, and potentially for other remote technologies.

Serological surveillance of influenza in an English sentinel network: pilot study protocol.

BACKGROUND: Rapidly undertaken age-stratified serology studies can produce valuable data about a new emerging infection including background population immunity and seroincidence during an influenza pandemic. Traditionally seroepidemiology studies have used surplus laboratory sera with little or no clinical information or have been expensive detailed population based studies. We propose collecting population based sera from the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), a sentinel network with extensive clinical data. AIM: To pilot a mechanism to undertake population based surveys that collect serological specimens and associated patient data to measure seropositivity and seroincidence due to seasonal influenza, and create a population based serology bank. METHODS AND ANALYSIS: Setting and Participants: We will recruit 6 RCGP RSC practices already taking nasopharyngeal virology swabs. Patients who attend a scheduled blood test will be consented to donate additional blood samples. Approximately 100-150 blood samples will be collected from each of the following age bands - 18- 29, 30- 39, 40- 49, 50- 59, 60- 69 and 70+ years. METHODS: We will send the samples to the Public Health England (PHE) Seroepidemiology Unit for processing and storage. These samples will be tested for influenza antibodies, using haemagglutination inhibition assays. Serology results will be pseudonymised, sent to the RCGP RSC and combined using existing processes at the RCGP RSC secure hub. The influenza seroprevalence results from the RCGP cohort will be compared against those from the annual PHE influenza residual serosurvey. ETHICS AND DISSEMINATION: Ethical approval was granted by the Proportionate Review Sub- Committee of the London - Camden & Kings Cross on 6 February 2018. This study received approval from Health Research Authority on 7 February 2018. On completion the results will be made available via peer-reviewed journals.

Quality improvement of prescribing safety: a pilot study in primary care using UK electronic health records.

BACKGROUND: Quality improvement (QI) is a priority for general practice, and GPs are expected to participate in and provide evidence of QI activity. There is growing interest in harnessing the potential of electronic health records (EHR) to improve patient care by supporting practices to find cases that could benefit from a medicines review. AIM: To develop scalable and reproducible prescribing safety reports using patient-level EHR data. DESIGN AND SETTING: UK general practices that contribute de-identified patient data to the Clinical Practice Research Datalink (CPRD). METHOD: A scoping phase used stakeholder consultations to identify primary care QI needs and potential indicators. QI reports containing real data were sent to 12 pilot practices that used Vision GP software and had expressed interest. The scale-up phase involved automating production and distribution of reports to all contributing practices that used both Vision and EMIS software systems. Benchmarking reports with patient-level case review lists for two prescribing safety indicators were sent to 457 practices in December 2017 following the initial scale-up (Figure 2). RESULTS: Two indicators were selected from the Royal College of General Practitioners Patient Safety Toolkit following stakeholder consultations for the pilot phase involving 12 GP practices. Pilot phase interviews showed that reports were used to review individual patient care, implement wider QI actions in the practice, and for appraisal and revalidation. CONCLUSION: Electronic health record data can be used to provide standardised, reproducible reports that can be delivered at scale with minimal resource requirements. These can be used in a national QI initiative that impacts directly on patient care.

Conurbation, Urban, and Rural Living as Determinants of Allergies and Infectious Diseases: Royal College of General Practitioners Research and Surveillance Centre Annual Report 2016-2017.

BACKGROUND: Living in a conurbation, urban, or rural environment is an important determinant of health. For example, conurbation and rural living is associated with increased respiratory and allergic conditions, whereas a farm or rural upbringing has been shown to be a protective factor against this. OBJECTIVE: The objective of the study was to assess differences in general practice presentations of allergic and infectious disease in those exposed to conurbation or urban living compared with rural environments. METHODS: The population was a nationally representative sample of 175 English general practices covering a population of over 1.6 million patients registered with sentinel network general practices. General practice presentation rates per 100,000 population were reported for allergic rhinitis, asthma, and infectious conditions grouped into upper and lower respiratory tract infections, urinary tract infection, and acute gastroenteritis by the UK Office for National Statistics urban-rural category. We used multivariate logistic regression adjusting for age, sex, ethnicity, deprivation, comorbidities, and smoking status, reporting odds ratios (ORs) with 95% CIs. RESULTS: For allergic rhinitis, the OR was 1.13 (95% CI 1.04-1.23; P=.003) for urban and 1.29 (95% CI 1.19-1.41; P<.001) for conurbation compared with rural dwellers. Conurbation living was associated with a lower OR for both asthma (OR 0.70, 95% CI 0.67-0.73; P<.001) and lower respiratory tract infections (OR 0.94, 95% CI 0.90-0.98; P=.005). Compared with rural dwellers, the OR for upper respiratory tract infection was greater in urban (OR 1.06, 95% CI 1.03-1.08; P<.001) but no different in conurbation dwellers (OR 1.00, 95% CI 0.97-1.03; P=.93). Acute gastroenteritis followed the same pattern: the OR was 1.13 (95% CI 1.01-1.25; P=.03) for urban dwellers and 1.04 (95% CI 0.93-1.17; P=.46) for conurbation dwellers. The OR for urinary tract infection was lower for urban dwellers (OR 0.94, 95% CI 0.89-0.99; P=.02) but higher in conurbation dwellers (OR 1.06, 95% CI 1.00-1.13; P=.04). CONCLUSIONS: Those living in conurbations or urban areas were more likely to consult a general practice for allergic rhinitis and upper respiratory tract infection. Both conurbation and rural living were associated with an increased risk of urinary tract infection. Living in rural areas was associated with an increased risk of asthma and lower respiratory tract infections. The data suggest that living environment may affect rates of consultations for certain conditions. Longitudinal analyses of these data would be useful in providing insights into important determinants.

Incidence of Lower Respiratory Tract Infections and Atopic Conditions in Boys and Young Male Adults: Royal College of General Practitioners Research and Surveillance Centre Annual Report 2015-2016.

BACKGROUND: The Royal College of General Practitioners Research and Surveillance Centre comprises more than 150 general practices, with a combined population of more than 1.5 million, contributing to UK and European public health surveillance and research. OBJECTIVE: The aim of this paper was to report gender differences in the presentation of infectious and respiratory conditions in children and young adults. METHODS: Disease incidence data were used to test the hypothesis that boys up to puberty present more with lower respiratory tract infection (LRTI) and asthma. Incidence rates were reported for infectious conditions in children and young adults by gender. We controlled for ethnicity, deprivation, and consultation rates. We report odds ratios (OR) with 95% CI, P values, and probability of presenting. RESULTS: Boys presented more with LRTI, largely due to acute bronchitis. The OR of males consulting was greater across the youngest 3 age bands (OR 1.59, 95% CI 1.35-1.87; OR 1.13, 95% CI 1.05-1.21; OR 1.20, 95% CI 1.09-1.32). Allergic rhinitis and asthma had a higher OR of presenting in boys aged 5 to 14 years (OR 1.52, 95% CI 1.37-1.68; OR 1.31, 95% CI 1.17-1.48). Upper respiratory tract infection (URTI) and urinary tract infection (UTI) had lower odds of presenting in boys, especially those older than 15 years. The probability of presenting showed different patterns for LRTI, URTI, and atopic conditions. CONCLUSIONS: Boys younger than 15 years have greater odds of presenting with LRTI and atopic conditions, whereas girls may present more with URTI and UTI. These differences may provide insights into disease mechanisms and for health service planning.

Understanding usual care for patients with multimorbidity: baseline data from a cluster-randomised trial of the 3D intervention in primary care.

OBJECTIVES: Recent evidence has highlighted the high prevalence and impact of multimorbidity, but the evidence base for improving management is limited. We have tested a new complex intervention for multimorbidity (the 3D model). The paper describes the baseline characteristics of practices and patients in order to establish the external validity of trial participants. It also explores current 'usual primary care' for multimorbidity, against which the 3D intervention was tested. DESIGN: Analysis of baseline data from patients in a cluster-randomised controlled trial and additional data from practice staff. SETTING: Primary care in the UK. PARTICIPANTS: Patients with multimorbidity (n=5253) and 154 practice staff. PRIMARY AND SECONDARY OUTCOME MEASURES: Using surveys and routinely available data, we compared the characteristics of participating and non-participating practices and participating and non-participating eligible patients.Baseline questionnaire data from patient participants was used to examine participant illness burden, treatment burden and perceptions of receiving patient-centred care. We obtained data about usual care preintervention from practice staff using questionnaires and a structured pro forma. RESULTS: Participating practices were slightly larger, in less deprived areas, and with slightly higher scores for patient satisfaction compared with non-participating practices. Patients with dementia or learning difficulties were likely to be excluded by their general practitioners, but comparison of participants with non-participants identified only minor differences in characteristics, suggesting that the sample was otherwise representative. Patients reported substantial illness burden, and an important minority reported high treatment burden. Although patients reported relatively high levels of satisfaction with care, many reported not having received potentially important components of care. CONCLUSION: This trial achieved good levels of external validity. Although patients were generally satisfied with primary care services, there was significant room for improvement in important aspects of care for multimorbidity that are targeted by the 3D intervention. TRIAL REGISTRATION NUMBER: ISRCTN06180958; Post-results.

Nurse-led cancer genetics clinics in primary and secondary care in varied ethnic population areas: interaction with primary care to improve ascertainment of individuals from ethnic minorities.

Genetic services are receiving increasing numbers of referrals of people with a family history of cancer for assessment of genetic risk, and therefore need to find cost-effective ways of meeting this rising demand. General Practitioners (GPs) are known to be reluctant to take on genetic consultations. Current evidence suggests that black and ethnic minorities are poorly represented in cancer genetics clinics. Nurse-led clinics in primary care have been found to be successful. This paper reports a pilot study to test the feasibility, accessibility, and effectiveness of providing cancer genetics nurse-counsellor clinics in primary and secondary care in the SW Thames Region. We initially set up three nurse-led clinics in general practices and two in district hospitals with very different ethnic catchment areas. The service was advertised by displaying posters and leaflets, translated into different languages. Self-referrals were encouraged. We set up a user involvement sub-group and held two focus group meetings to assess barriers to, and satisfaction with, the service. A patient satisfaction questionnaire was designed and administered after the appointments. We also designed a GP satisfaction survey regarding the service. Data on referrals, including their source and outcome, were recorded on a purpose-designed study database. We received increasing numbers of referrals to all clinics over the course of the pilot. Of 137 referrals, 23 (17%) were from ethnic minorities, of whom 17/23 (74%) were self-referred, compared with 102 British White referrals, of whom 91/102 (89%) were self-referred. Sixty-two patients (45%) were assessed to be at population risk and reassured, 60 (44%) were at moderate risk, and 15 (11%) were at high risk and were referred on for appropriate management. These proportions were similar for black and ethnic minority patients. Most patients reported high satisfaction with the service.