Pathological changes in the primary visual cortex (Area V1) in Creutzfeldt-Jakob syndrome

About 10% of patients with Creutzfeldt-Jakob syndrome (disease) (CJD) exhibit visual symptoms at presentation and approximately 50% during the course of the disease. The objectives of the present study were to determine, in two subtypes of CJD, viz., sporadic CJD (sCJD) and variant CJD (vCJD), the degree of pathological change in the primary visual cortex (area V1) and the extent to which pathology in V1 may influence visual function. The vacuolation (‘spongiform change’), surviving neurons, glial cell nuclei, and deposits of prion protein (PrP) were quantified in V1 obtained post-mortem in nine cases of sCJD and eleven cases of vCJD. In sCJD, the vacuoles and PrP deposits were regularly distributed along the cortex parallel to the pia mater in clusters with a mean dimension from 450 to 1000 µm. Across the cortex, the vacuolation was most severe in laminae II/III and the glial cell reaction in laminae V/VI. Surviving neurons were most abundant in laminae II/III while PrP deposition either affected all laminae equally or was maximal in lamina II/III. In vCJD, the vacuoles and diffuse PrP deposits were distributed relatively uniformly parallel to the pia mater while the florid deposits were consistently distributed in regular clusters. Across V1, the vacuoles either exhibited a bimodal distribution or were uniformly distributed. The diffuse PrP deposits occurred most frequently in laminae II/III while the florid deposits were more generally distributed. The data suggest that in both sCJD and vCJD, pathological changes in area V1 may affect the processing of visual information in laminae II/III and its transmission from V1 to V2 and to subcortical visual areas. In addition, the data suggest an association in sCJD between the developing pathology and the functional domains of V1 while in vCJD the pathology is more uniformly distributed. These changes could be a factor in the development of poor visual acuity, visual field defects, cortical blindness, diplopia, and vertical gaze palsy that have been observed in Creutzfeldt-Jakob syndrome.

Pathological changes in the primary visual cortex (area V1) in sporadic Creutzfeldt-Jakob disease

Purpose. To determine the degree of pathological change in the primary visual cortex (area V1) in patients with Creutzfeldt-Jakob disease. Method. The vacuolation, surviving neurons, glial cells, and deposits of prion protein were quantified in area V1 obtained postmortem in nine cases of the sporadic type of Creutzfeldt-Jakob disease. Results. Variations in the density of glial cells and in prion protein deposition were particularly evident between patients. In the upper and lower cortical laminae, vacuoles and prion protein deposits were regularly distributed in clusters with a mean dimensions of 450 to 1000 µm. Vacuolation in area V1 was most severe in lamina III and the glial cell reaction in lamina V or VI. Surviving neurons were most abundant in lamina II or III, whereas prion protein deposition either affected all laminae equally or was maximal in lamina II or III. Conclusion. The data suggest that pathological changes in area V1 in sporadic type of Creutzfeldt-Jakob disease may affect the transmission of visual information from area V1 to V2 and to subcortical visual areas. In addition, the data suggest an association between the developing pathology and the functional domains of area V1.

Correlates of spontaneous reporting of adverse drug reactions within primary care: the paradox of low prescribers who are high reporters

AIM(S) To examine Primary Care Trust (PCT) demographics influencing general practitioner (GP) involvement in pharmacovigilance. METHODS PCT adverse drug reaction (ADR) reports to the Yellow Card scheme between April 2004 and March 2006 were obtained for the UK West Midlands region. Reports were analysed by all drugs, and most commonly reported drugs (‘top drugs’). PCT data, adjusted for population size, were aggregated. Prescribing statistics and other characteristics were obtained for each PCT, and associations between these characteristics and ADR reporting rates were examined. RESULTS During 2004–06, 1175 reports were received from PCTs. Two hundred and eighty (24%) of these reports were for 14 ‘top drugs’. The mean rate of reporting for PCTs was 213 reports per million population. A total of 153 million items were prescribed during 2004–06, of which 33% were ‘top drugs’. Reports for all drugs and ‘top drugs’ were inversely correlated with the number of prescriptions issued per thousand population (rs = -0.413, 95% CI -0.673, -0.062, P < 0.05, and r = -0.420, 95% CI -0.678, -0.071, P < 0.05, respectively). Reporting was significantly negatively correlated with the percentages of male GPs within a PCT, GPs over 55 years of age, single-handed GPs within a PCT, the average list size of a GP within a PCT, the overall deprivation scores and average QOF total points. ADR reports did not correlate significantly with the proportion of the population over 65 years old. CONCLUSIONS Some PCT characteristics appear to be associated with low levels of ADR reporting. The association of low prescribing areas with high ADR reporting rates replicates previous findings.

Evaluation of the Heart of Birmingham teaching Primary Care Trust (HoBtPCT): My Choice Weight Management Programme:report commissioned by Heart of Birmingham teaching Primary Care Trust

This report details an evaluation of the My Choice Weight Management Programme undertaken by a research team from the School of Pharmacy at Aston University. The My Choice Weight Management Programme is delivered through community pharmacies and general practitioners (GPs) contracted to provide services by the Heart of Birmingham teaching Primary Care Trust. It is designed to support individuals who are ‘ready to change’ by enabling the individual to work with a trained healthcare worker (for example, a healthcare assistant, practice nurse or pharmacy assistant) to develop a care plan designed to enable the individual to lose 5-10% of their current weight. The Programme aims to reduce adult obesity levels; improve access to overweight and obesity management services in primary care; improve diet and nutrition; promote healthy weight and increased levels of physical activity in overweight or obese patients; and support patients to make lifestyle changes to enable them to lose weight. The Programme is available for obese patients over 18 years old who have a Body Mass Index (BMI) greater than 30 kg/m2 (greater than 25 kg/m2 in Asian patients) or greater than 28 kg/m2 (greater than 23.5 kg/m2 in Asian patients) in patients with co-morbidities (diabetes, high blood pressure, cardiovascular disease). Each participant attends weekly consultations over a twelve session period (the final iteration of these weekly sessions is referred to as ‘session twelve’ in this report). They are then offered up to three follow up appointments for up to six months at two monthly intervals (the final of these follow ups, taking place at approximately nine months post recruitment, is referred to as ‘session fifteen’ in this report). A review of the literature highlights the dearth of published research on the effectiveness of primary care- or community-based weight management interventions. This report may help to address this knowledge deficit. A total of 451 individuals were recruited on to the My Choice Weight Management Programme. More participants were recruited at GP surgeries (n=268) than at community pharmacies (n=183). In total, 204 participants (GP n=102; pharmacy n=102) attended session twelve and 82 participants (GP n=22; pharmacy 60) attended session fifteen. The unique demographic characteristics of My Choice Weight Management Programme participants – participants were recruited from areas with high levels of socioeconomic deprivation and over four-fifths of participants were from Black and Minority Ethnic groups; populations which are traditionally underserved by healthcare interventions – make the achievements of the Programme particularly notable. The mean weight loss at session 12 was 3.8 kg (equivalent to a reduction of 4.0% of initial weight) among GP surgery participants and 2.4 kg (2.8%) among pharmacy participants. At session 15 mean weight loss was 2.3 kg (2.2%) among GP surgery participants and 3.4 kg (4.0%) among pharmacy participants. The My Choice Weight Management Programme improved the general health status of participants between recruitment and session twelve as measured by the validated SF-12 questionnaire. While cost data is presented in this report, it is unclear which provider type delivered the Programme more cost-effectively. Attendance rates on the Programme were consistently better among pharmacy participants than among GP participants. The opinions of programme participants (both those who attended regularly and those who failed to attend as expected) and programme providers were explored via semi-structured interviews and, in the case of the participants, a selfcompletion postal questionnaire. These data suggest that the Programme was almost uniformly popular with both the deliverers of the Programme and participants on the Programme with 83% of questionnaire respondents indicating that they would be happy to recommend the Programme to other people looking to lose weight. Our recommendations, based on the evidence provided in this report, include: a. Any consideration of an extension to the study also giving comparable consideration to an extension of the Programme evaluation. The feasibility of assigning participants to a pharmacy provider or a GP provider via a central allocation system should also be examined. This would address imbalances in participant recruitment levels between provider type and allow for more accurate comparison of the effectiveness in the delivery of the Programme between GP surgeries and community pharmacies by increasing the homogeneity of participants at each type of site and increasing the number of Programme participants overall. b. Widespread dissemination of the findings from this review of the My Choice Weight Management Project should be undertaken through a variety of channels. c. Consideration of the inclusion of the following key aspects of the My Choice Weight Management Project in any extension to the Programme: i. The provision of training to staff in GP surgeries and community pharmacies responsible for delivery of the Programme prior to patient recruitment. ii. Maintaining the level of healthcare staff input to the Programme. iii. The regular schedule of appointments with Programme participants. iv. The provision of an increased variety of printed material. d. A simplification of the data collection method used by the Programme commissioners at the individual Programme delivery sites.

Generation of primary hepatocyte microarrays by piezoelectric printing

We demonstrate a single-step method for the generation of collagen and poly-l-Lysine (PLL) micropatterns on a poly(ethylene glycol) (PEG) functionalized glass surface for cell based assays. The method involves establishing a reliable silanization method to create an effective non-adhesive PEG layer on glass that inhibits cell attachment, followed by the spotting of collagen or PLL solutions using non-contact piezoelectric printing. We show for the first time that the spotted protein micropatterns remain stable on the PEG surface even after extensive washing, thus significantly simplifying protein pattern formation. We found that adherence and spreading of NIH-3T3 fibroblasts was confined to PLL and collagen areas of the micropatterns. In contrast, primary rat hepatocytes adhered and spread only on collagen micropatterns, where they formed uniform, well defined functionally active cell arrays. The differing affinity of hepatocytes and NIH-3T3 fibroblasts for collagen and PLL patterns was used to develop a simple technique for creating a co-culture of the two cell types. This has the potential to form structured arrays that mimic the in vivo hepatic environment and is easily integrated within a miniaturized analytical platform for developing high throughput toxicity analysis in vitro.

Analysis of organisational climate to improve the adequacy of primary health care in the State of Kuwait

This study covers two areas of contribution to the knowledge, firstly it tried to investigate rigourously the relationships of a number of factors believed that they may affect the climate perception, classified into three types to arrive to prove a hypothesis of the important role that qualification and personal factors play in shaping the climate perception, this is in contrast with situational factors. Secondly, the study tries to recluster the items of a wide-range applied scale for the measurement of climate named HAY in order to overcome the cross-cultural differences between the Kuwaiti and the American society, and to achieve a modified dimensions of climate for a civil service organisation in Kuwait. Furthermore, the study attempts to carry out a diagnostic test for the climate of the Ministry of Public Health in Kuwait, aiming to diagnose the perceived characteristics of the MoPH organisation, and suggests a number of areas to be given attention if an improvement is to be introduced. The study used extensively the statistical and the computer facilities to make the analysis more representing the field data, on the other hand this study is characterised by the very highly responsive rate of the main survey which would affect the findings reliability. Three main field studies are included, the first one was to conduct the main questionnaire where the second was to measure the "should be" climate by the experts of MoPH using the DELPHI technique, and the third was to conduct an extensive meeting with the very top management team in MoPH. Results of the first stage were subject to CLUSTER analysis for the reconstruction of the HAY tool, whereas comparative analysis was carried on between the results of the second and third stages on one side, the first from the other.

Maintenance of communication in primary classrooms : some evidence for the role of elicitation and code-switching in English medium schools in Kenya, with implications for teaching

This is a study of specific aspects of classroom interaction primary school level in Kenya. The study entailed the identification of the sources of particular communication problems during the change-over period from Kiswahili to English medium teaching in two primary schools. There was subsequently an examination of the language resources which were employed by teachers to maintain pupil participation in communication in the light of the occurrence of possibility of occurrence of specific communication problems. The language resources which were found to be significant in this regard concerned firstly the use of different elicitation types by teachers to stimulate pupils into giving responses and secondly teachers' recourse to code-switching from English to Kiswahili and vice-versa. It was also found in this study that although the use of English as the medium of instruction in the classrooms which were observed resulted in certain communication problems, some of these problems need not have arisen if teachers had been more careful in their use of language. The consideration of this finding, after taking into account the role of different elicitation types and code-switching as interpretable from data samples had certain implications which are specified in the study for teaching in Kenyan primary schools. The corpus for the study consisted of audio-recordings of English, Science and Number-Work lessons which were later transcribed. Relevant data samples were subsequently extracted from transcripts for analysis. Many of the samples have examples of cases of communication breakdowns, but they also illustrate how teachers maintained interaction with pupils who had yet to acquire an operational mastery of English. This study thus differs from most studies on classroom interaction because of its basic concern with the examination of the resources available to teachers for overcoming the problem areas of classroom communication.

Optimising primary care for people with dementia

This review considers key areas in primary care regarding the diagnosis of dementia. Issues surrounding assessment, policy and incentives are considered. In addition, the relevance of non-medication approaches for dementia in primary care, which aim to enhance or maintain quality of life by maximising psychological and social function in the context of existing disabilities, is deliberated. Finally, key issues about primary care medication management are considered, and relevant therapeutic strategies with recommendation for a collaborative approach that improve outcomes by linking primary and secondary healthcare services - including general practice and pharmacy - with social care needs are weighed up. A key aspect of such a collaborative approach is to support informal carers in optimising medication.

GPs' perspectives on managing the NHS Health Check in primary care:a qualitative evaluation of implementation in one area of England

OBJECTIVES: To evaluate the implementation of the National Health Service (NHS) Health Check programme in one area of England from the perspective of general practitioners (GPs). DESIGN: A qualitative exploratory study was conducted with GPs and other healthcare professionals involved in delivering the NHS Health Check and with patients. This paper reports the experience of GPs and focuses on the management of the Heath Check programme in primary care. SETTING: Primary care surgeries in the Heart of Birmingham region (now under the auspices of the Birmingham Cross City Clinical Commissioning Group) were invited to take part in the larger scale evaluation. This study focuses on a subset of those surgeries whose GPs were willing to participate. PARTICIPANTS: 9 GPs from different practices volunteered. GPs served an ethnically diverse region with areas of socioeconomic deprivation. Ethnicities of participant GPs included South Asian, South Asian British, white, black British and Chinese. METHODS: Individual semistructured interviews were conducted with GPs face to face or via telephone. Thematic analysis was used to analyse verbatim transcripts. RESULTS: Themes were generated which represent GPs' experiences of managing the NHS Health Check: primary care as a commercial enterprise; 'buy in' to concordance in preventive healthcare; following protocol and support provision. These themes represent the key issues raised by GPs. They reveal variability in the implementation of NHS Health Checks. GPs also need support in allocating resources to the Health Check including training on how to conduct checks in a concordant (or collaborative) way. CONCLUSIONS: The variability observed in this small-scale evaluation corroborates existing findings suggesting a need for more standardisation. Further large-scale research is needed to determine how that could be achieved. Work needs to be done to further develop a concordant approach to lifestyle advice which involves tailored individual goal setting rather than a paternalistic advice-giving model.

Historic primary producer communities linked to water quality and hydrologic changes in the northern Everglades

The northern Everglades Water Conservation Areas have experienced recent ecological shifts in primary producer community structure involving marl periphyton mats and dense Typha-dominated macrophyte stands. Multiple investigations have identified phosphorus (P) as a driver of primary producer community structure, but effects of water impoundment beginning in the 1950s and changes in water hardness [e.g., (CaCO3)] have also been identified as a concern. In an effort to understand pre-1950, primary producer community structure and identify community shifts since 1950, we measured pigment proxies on three sediment cores collected in Water Conservation Area-2A (WCA-2A) along a phosphorus enrichment gradient. Photosynthetic pigments, sediment total phosphorus content (TP), organic matter, total organic carbon and nitrogen were used to infer historic primary producer communities and changes in water quality and hydrology regulating those communities. Excess 210Pb was used to establish historic dates for the sediment cores. Results indicate the northern area of WCA-2A increased marl deposition and increased algal abundance ca. 1920. This increase in (presumably) calcareous periphyton before intensive agriculture and impoundment suggest canal-derived calcium inputs and to some extent early drainage effects played a role in initiating this community shift. The northern area community then shifted to Typha dominance around 1965. The areas to the south in WCA-2A experienced increased marl deposition and algal abundance around or just prior to 1950s impoundment, the precise timing limited by core age resolution. Continued increases in algal abundance were evident after 1950, coinciding with impoundment and deepening of canals draining into WCA-2A, both likely increasing water mineral and nutrient concentrations. The intermediate site developed a Typha-dominated community ca. 1995 while the southern-most core site WCA-2A has yet to develop Typha dominance. Numerous studies link sediment TP >650 mg P/kg to marsh habitat degradation into Typha-dominance. The northern and intermediate cores where Typha is currently support this previous research by showing a distinct shift in the sediment record to Typha dominance corresponding to sediment TP between 600 and 700 mg P/kg. These temporal and spatial differences are consistent with modern evidence showing water-column gradients in mineral inputs (including Ca, carbonates, and phosphorus) altering primary producer community structure in WCA-2A, but also suggest hydroperiod has an effect on the mechanisms regulating periphyton development and Typha dominance.

Assessment in primary education in Ireland

This doctoral study examines assessment in primary education in the Republic of Ireland. The nature and purpose of assessment offer an insight into the values which are prioritised by an education system. In 2011, in the Republic of Ireland, the Department of Education and Skills (DES) published a strategy aiming to improve standards of literacy and numeracy. The document, entitled, Literacy and numeracy for learning and life: the national strategy to improve literacy and numeracy for children and young people 2011-2020, contains improvement targets as measured by standardised tests. It also mandates the increased use of standardised tests in primary education, and directs that aggregated scores should be reported to both Boards of Management and the DES. The study is framed by the theoretical perspectives of Michel Foucault and Pierre Bourdieu. Both of these commentators examine social policy and practice in an effort to provide insight into the history and operation of social institutions. This study is especially influenced by Foucault’s archaeology and genealogy of knowledge, and his notion of governmentality. It is also particularly cognisant of Bourdieu’s thoughts on habitus, doxa and capital. The study contains reviews of literature in the areas of assessment, assessment policy, and assessment policy in Ireland. These reviews highlight current debate in each of these areas while also grounding this debate in an historical context. The dissertation contains four empirical sections. 1) It analyses policy documents prepared in the development of the published strategy as well as investigating the strategy itself. In so doing it is aware of the burgeoning influence of pan-national bodies on policy development. 2) A number of high profile policy makers were interviewed as part of the study and their views are interpreted in light of the findings of the literature reviews. 3) The perspective of teachers was sought through a questionnaire survey. This gathered data on these teachers’ views on the purpose of assessment as well as their actual practice. 4) Finally, children were also included as participants in this study. They were interviewed in focus groups and encouraged to contribute drawings as well on their views of assessment in primary school. Literacy and numeracy for learning and life is seen as a seminal document in Irish education. This study is significant in its analysis of original data from high profile policy makers, including two Ministers for Education and Skills. It is also significant in its inclusion of the perspectives of primary school pupils. Finally, the study considers the nature and role of assessment in a holistic manner by including the views of policy makers, teachers and pupils. The study notes that policy development in Ireland underwent a change in the preparation of Literacy and numeracy for learning and life and that international influences, while present, are also mediated to suit the local context. It also highlights a lack of clarity in the definition of assessment in primary education and argues that there is a lack of balance in the approaches that are prioritised. The study demonstrates that teachers are impacted by the strategy but that they also change it by focusing on their own concerns while using assessment tools. The children provide compelling evidence of the impact of assessment on the learner. The study shows how assessment tools (and school subjects) are valued with differing levels of importance by a variety of stakeholders.

Phonic skills mediate improved literacy outcomes in at-risk primary school children: results from the Ready-to-Learn Programme

Background
Learning to read is a key goal during primary school: reading difficulties may curtail children’s learning trajectories. Controversy remains regarding what types of interventions are effective for children at risk for academic failure, such as children in disadvantaged areas. We present data from a complex intervention to test the hypothesis that phonic skills and word recognition abilities are a pivotal and specific causal mechanism for the development of reading skills in children at risk for poorer literacy outcomes.
Method
Over 500 pupils across 16 primary schools took part in a Cluster Randomised Controlled Trial from school year 1 to year 3. Schools were randomly allocated to the intervention or the control arm. The intervention involved a literacy-rich after-school programme. Children attending schools in the control arm of the study received the curriculum normally provided. Children in both arms completed batteries of language, phonic skills, and reading tests every year. We used multilevel mediation models to investigate mediating processes between intervention and outcomes.
Findings
Children who took part in the intervention displayed improvements in reading skills compared to those in the control arm. Results indicated a significant indirect effect of the intervention via phonics encoding.
Discussion
The results suggest that the intervention was effective in improving reading abilities of children at risk, and this effect was mediated by improving children’s phonic skills. This has relevance for designing interventions aimed at improving literacy skills of children exposed to socio-economic disadvantage. Results also highlight the importance of methods to investigate causal pathways from intervention to outcomes.

The four general principles of the United Nations Convention on the Rights of the Child: the potential value of the approach in other areas of human rights law

At the outset of the United Nations Convention on the Rights of the Child, the Committee on the Rights of the Child identified four of its provisions (non-discrimination; best interests of the child as a primary consideration; life, survival and development; and participation) as ‘general principles’. This approach has shaped implementation of, advocacy for and the scholarship on the Convention. The use of general principles has the potential to make a significant contribution in other areas of human rights law provided that the principles are selected carefully and address the distinct issues at the root of potential rights violations for particular rights-holders.

Optimization of flocculation process and continuous filtration for sea water primary treatment filtration to reduce SDI for entree to reverse osmosis system

Today , Providing drinking water and process water is one of the major problems in most countries ; the surface water often need to be treated to achieve necessary quality, and in this way, technological and also financial difficulties cause great restrictions in operating the treatment units. Although water supply by simple and cheap systems has been one of the important objectives in most scientific and research centers in the world, still a great percent of population in developing countries, especially in rural areas, don't benefit well quality water. One of the big and available sources for providing acceptable water is sea water. There are two ways to treat sea water first evaporation and second reverse osmosis system. Nowadays R.O system has been used for desalination because of low budget price and easily to operate and maintenance. The sea water should be pretreated before R.O plants, because there is some difficulties in raw sea water that can decrease yield point of membranes in R.O system. The subject of this research may be useful in this way, and we hope to be able to achieve complete success in design and construction of useful pretreatment systems for R.O plant. One of the most important units in the sea water pretreatment plant is filtration, the conventional method for filtration is pressurized sand filters, and the subject of this research is about new filtration which is called continuous back wash sand filtration (CBWSF). The CBWSF designed and tested in this research may be used more economically with less difficulty. It consists two main parts first shell body and second central part comprising of airlift pump, raw water feeding pipe, air supply hose, backwash chamber and sand washer as well as inlet and outlet connections. The CBWSF is a continuously operating filter, i.e. the filter does not have to be taken out of operation for backwashing or cleaning. Inlet water is fed through the sand bed while the sand bed is moving downwards. The water gets filtered while the sand becomes dirty. Simultaneously, the dirty sand is cleaned in the sand washer and the suspended solids are discharged in backwash water. We analyze the behavior of CBWSF in pretreatment of sea water instead of pressurized sand filter. There is one important factor which is not suitable for R.O membranes, it is bio-fouling. This factor is defined by Silt Density Index (SDI).measured by SDI. In this research has been focused on decreasing of SDI and NTU. Based on this goal, the prototype of pretreatment had been designed and manufactured to test. The system design was done mainly by using the design fundamentals of CBWSF. The automatic backwash sand filter can be used in small and also big water supply schemes. In big water treatment plants, the units of filters perform the filtration and backwash stages separately, and in small treatment plants, the unit is usually compacted to achieve less energy consumption. The analysis of the system showed that it may be used feasibly for water treating, especially for limited population. The construction is rapid, simple and economic, and its performance is high enough because no mobile mechanical part is used in it, so it may be proposed as an effective method to improve the water quality and consequently the hygiene level in the remote places of the country.

Tackling health inequalities in primary care: an exploration of GPs’ experience at the frontline

In Scotland, life expectancy and health outcomes are strongly tied to socioeconomic status. Specifically, socioeconomically deprived areas suffer disproportionately from high levels of premature multimorbidity and mortality. To tackle these inequalities in health, challenges in the most deprived areas must be addressed. One avenue that merits attention is the potential role of general medical practitioners (GPs) in helping to address health inequalities, particularly due to their long-term presence in deprived communities, their role in improving patient and population health, and their potential advocacy role on behalf of their patients. GPs can be seen as what Lipsky calls ‘street-level bureaucrats’ due to their considerable autonomy in the decisions they make surrounding individual patient needs, yet practising under the bureaucratic structure of the NHS. While previous research has examined the applicability of Lipsky’s framework to the role of GPs, there has been very little research exploring how GPs negotiate between the multiple identities in their work, how GPs ‘socially construct’ their patients, how GPs view their potential role as ‘advocate’, and what this means in terms of the contribution of GPs to addressing existing inequalities in health. Using semi-structured interviews, this study explored the experience and views of 24 GPs working in some of Scotland’s most deprived practices to understand how they might combat this growing health divide via the mitigation (and potential prevention) of existing health inequalities. Participants were selected based on several criteria including practice deprivation level and their individual involvement in the Deep End project, which is an informal network comprising the 100 most deprived general practices in Scotland. The research focused on understanding GPs’ perceptions of their work including its broader implications, within their practice, the communities within which they practise, and the health system as a whole. The concept of street-level bureaucracy proved to be useful in understanding GPs’ frontline work and how they negotiate dilemmas. However, this research demonstrated the need to look beyond Lipsky’s framework in order to understand how GPs reconcile their multiple identities, including advocate and manager. As a result, the term ‘street-level professional’ is offered to capture more fully the multiple identities which GPs inhabit and to explain how GPs’ elite status positions them to engage in political and policy advocacy. This study also provides evidence that GPs’ social constructions of patients are linked not only to how GPs conceptualise the causes of health inequalities, but also to how they view their role in tackling them. In line with this, the interviews established that many GPs felt they could make a difference through advocacy efforts at individual, community and policy/political levels. Furthermore, the study draws attention to the importance of practitioner-led groups—such as the Deep End project—in supporting GPs’ efforts and providing a platform for their advocacy. Within this study, a range of GPs’ views have been explored based on the sample. While it is unclear how common these views are amongst GPs in general, the study revealed that there is considerable scope for ‘political GPs’ who choose to exercise discretion in their communities and beyond. Consequently, GPs working in deprived areas should be encouraged to use their professional status and political clout not only to strengthen local communities, but also to advocate for policy change that might potentially affect the degree of disadvantage of their patients, and levels of social and health inequalities more generally.