What do we know about demand, use and outcomes in primary care out-of-hours services? A systematic scoping review of international literature.

OBJECTIVE: To synthesise international evidence for demand, use and outcomes of primary care out-of-hours health services (OOHS). DESIGN: Systematic scoping review. DATA SOURCES: CINAHL; Medline; PsyARTICLES; PsycINFO; SocINDEX; and Embase from 1995 to 2019. STUDY SELECTION: English language studies in UK or similar international settings, focused on services in or directly impacting primary care. RESULTS: 105 studies included: 54% from mainland Europe/Republic of Ireland; 37% from UK. Most focused on general practitioner-led out-of-hours cooperatives. Evidence for increasing patient demand over time was weak due to data heterogeneity, infrequent reporting of population denominators and little adjustment for population sociodemographics. There was consistent evidence of higher OOHS use in the evening compared with overnight, at weekends and by certain groups (children aged <5, adults aged >65, women, those from socioeconomically deprived areas, with chronic diseases or mental health problems). Contact with OOHS was driven by problems perceived as urgent by patients. Respiratory, musculoskeletal, skin and abdominal symptoms were the most common reasons for contact in adults; fever and gastrointestinal symptoms were the most common in the under-5s. Frequent users of daytime services were also frequent OOHS users; difficulty accessing daytime services was also associated with OOHS use. There is some evidence to suggest that OOHS colocated in emergency departments (ED) can reduce demand in EDs. CONCLUSIONS: Policy changes have impacted on OOHS over the past two decades. While there are generalisable lessons, a lack of comparable data makes it difficult to judge how demand has changed over time. Agreement on collection of OOHS data would allow robust comparisons within and across countries and across new models of care. Future developments in OOHS should also pay more attention to the relationship with daytime primary care and other services. PROSPERO REGISTRATION NUMBER: CRD42015029741.

'You certainly don't go back to the doctor once you've been told, "I'll never understand women like you."' Seeking candidacy and structural competency in the dynamics of domestic abuse disclosure.

A reticence on the part of women to disclose domestic abuse (DA) to family doctors, allied to front-line responses that do not always reflect an understanding of the structure and dynamics of DA, hampers the provision of professional support. Using data from 20 qualitative interviews with women who have experienced DA, this paper explores their discourse about interacting with family doctors. It is the first study to explore firsthand accounts of these interactions through Dixon Woods' lens of candidacy. It finds disclosure to be inherently dynamic as a process and expands the candidacy lens by considering the: (i) conflicting candidacies of victims and perpetrators; (ii) diversionary disclosure tactics deployed by perpetrators and, (iii) the potential role of General Practitioner (GPs) in imagining candidacies from a structural perspective. By exploring the dynamics of disclosure through the concept of 'structural competency' it finds that in encounters with women who have experienced abuse GPs ineluctably communicate their views on the legitimacy of women's claims for support; these in turn shape future candidacy and help-seeking. Greater GP awareness of the factors creating and sustaining abuse offers the potential for better care and reduced stigmatisation of abused women.

Capture--recapture and anchored prevalence estimation of injecting drug users in England: national and regional estimates.

Capture-recapture (C-RC) using four data sources, one of which accounted for 81% of captured injectors, and multiple indicator methods (MIM) were used to obtain national, regional and local estimates of the prevalence of injecting drug use among opiate and/or crack cocaine users in England. Persons aged 15 to 64 years, in contact with health and/or criminal justice services during 2005/2006, and known to be using opiates and/or crack cocaine and injecting drugs were included in the C-RC analysis. The MIM analysis included indicators relating to drug treatment, drug-related deaths, population density and drug offences.There were an estimated 130,000 opiate and/or crack cocaine users who injected drugs in 2005/06 (95% confidence interval 125,800 to 137,000), corresponding to 3.9 per thousand of the population aged 15 to 64 years (95% confidence interval 3.8-4.1). Regional variation in the prevalence of injecting was evident, ranging from 6.1 per thousand of the population aged 15 to 64 years in Yorkshire and the Humber (95% confidence interval 5.6 to 6.6) to 2.3 per thousand in the East of England (95% confidence interval 1.8 to 2.9). Application of gender and age-group distributions for treated injecting drug users (IDUs) to the prevalence estimates suggested that there were 97,200 male injectors (95% confidence interval 94,000 to 102,500) and 63,600 female injectors aged 25 to 34 years (95% confidence interval 61,500 to 67,000).The prevalence estimates provide a basis from which numbers of current IDUs infected with hepatitis C virus (HCV) can be approximated.

Increasing the uptake of cervical screening programmes.

Successful cervical screening programmes depend on the degree of coverage and the rate of attendance. There are many demographic reasons why some women fail to attend for cervical screening, including lack of knowledge and education and socioeconomic status. Moreover, a woman's ethnicity and her age also play a role in screening uptake. Community and practice nurses are ideally positioned to identify women's information needs and provide appropriate information to overcome barriers to screening attendance. This article discusses the main predictors of participation in cervical screening programmes and interventions that can be used to increase cervical screening uptake.

Contribution of problem drug users' deaths to excess mortality in Scotland: secondary analysis of cohort study.

OBJECTIVES: To examine the "Scottish effect"-namely, the growing divergence between mortality in Scotland and England that is not explained by national differences in levels of deprivation-and, more specifically, to examine the extent to which the Scottish effect is explained by cross national differences in the prevalence of problem drug use. DESIGN: Secondary analysis of cohort study (the DORIS study). PARTICIPANTS: 1033 Scottish drug users recruited to the cohort study in 33 drug treatment facilities across Scotland in 2001-2 and followed up 33 months later in 2004-5. RESULTS: 38 deaths occurred in the cohort, giving a standardised mortality ratio for the cohort of 1244 (95% credible interval 876 to 1678). Only 22 of the 38 deaths in drug users were classified as drug related deaths. From estimates of the size of the problem drug using populations in both England and Scotland, the contribution of deaths in drug users to national death rates can be estimated: the attributable risk fraction for Scotland is 17.3% (12.3% to 22.8%) and that for England is 11.1% (7.8% to 14.8%). Excluding estimated numbers of deaths in drug users would bring down age standardised mortality at ages 15-54 years from 196 to 162 per 100,000 in Scotland and from 138 to 122 per 100,000 in England; 32.0% (22.3% to 43.0%) of the excess mortality in Scotland is due to drug use. CONCLUSION: Although problem drug use is a low prevalence risk behaviour, it carries a high mortality; the standardised mortality ratio for Scottish drug users is 12 times as high as for the general population. The higher prevalence of problem drug use in Scotland than in England accounts for a third of Scotland's excess mortality over England. Successful public health efforts to reduce the prevalence of problem drug use in Scotland or deaths in Scottish drug users would have a dramatic impact on overall mortality in Scotland.

Drug misuse treatment services in Scotland: predicting outcomes.

OBJECTIVE: To investigate which aspects of treatment satisfaction are the best predictors of improved health, improved mental health and achievement of abstinence in drug misuse treatment services. DESIGN: Data were collected as part of the Drug Outcome Research in Scotland study, a prospective cohort study designed to evaluate drug misuse treatment provided in Scotland. Data were collected using a structured interview. Participants were recruited between 1 October 2001 and 30 June 2002. Follow-up interviews were carried out approximately 8 months later. Logistic regression analysis is used to explore client satisfaction with treatment on outcomes, using the Treatment Perceptions Questionnaire (discussed in Marsden et al., Assessing client satisfaction with treatment for substance use problems and the development of the Treatment Perceptions Questionnaire (TPQ). Addict Res 2000;8:455-70). SETTING: Prison, residential and community facilities. PARTICIPANTS: A total of 841 drug users starting a new episode of drug treatment in Scotland in 2000-01. INTERVENTIONS: Methadone, substitute drugs other than methadone, residential rehabilitation, residential detoxification and non-clinical. MAIN OUTCOME MEASURES: Reported improvements in physical health, mental health and abstinence. RESULTS: Client satisfaction predicted positive outcomes, independent of treatment setting. Predicting abstinence and improved physical and mental health were the items: 'I have received the help that I was looking for' and 'The staff have helped to motivate me to sort out my problems'. CONCLUSIONS: Feeling that treatment is appropriate, finding staff motivating, and having enough time to sort out problems are important aspects of satisfaction with treatment among users of drug treatment services who achieved positive treatment outcomes. Services should seek to provide more individualized services based on understanding of individual client needs. This may require longer treatment periods and greater client involvement.

Exposure to drugs among pre-teenage schoolchildren.

AIMS: To describe the nature and extent of exposure to drugs in a sample of pre-teenage children and to examine some of the factors that might be associated with it. PARTICIPANTS AND DESIGN: A survey of 1202 10-12-year-old children based on a questionnaire administered in schools under examination-type conditions. FINDINGS: A third of the children reported having been exposed to drugs in the sense of either having been in situations in which they were being used or of having been offered them. While the most common drug to which they were exposed was cannabis, considerable numbers had also been exposed to more dangerous drugs. The factors which were associated most closely with exposure were drug use by friends or family members, associating with peers who engaged in antisocial activities, the child's own involvement in problem behaviours and the regular consumption of alcohol. Boys and older children were also significantly more likely to be offered drugs. CONCLUSION: A large proportion of young children are exposed to illicit drugs primarily through use of these drugs by family members and peers. There is a strong association with antisocial behaviour. Attempting to influence such exposure is challenging but may be one avenue for reducing drug use in adolescents.