Tag: Primary Care

Impact of Remote Consultations on Antibiotic Prescribing in Primary Health Care: Systematic Review

here has been growing international interest in performing remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the evidence surrounding the safety of remote consultations is inconclusive. The appropriateness of antibiotic prescribing in remote consultations is an important aspect of patient safety that needs to be addressed. We aimed to summarize evidence on the impact of remote consultation in primary care with regard to antibiotic prescribing. The research was published in the Journal of Medical Internet Research.

In total, 12 studies were identified. Of these, 4 studies reported higher antibiotic-prescribing rates, 5 studies reported lower antibiotic-prescribing rates, and 3 studies reported similar antibiotic-prescribing rates in remote consultations compared with face-to-face consultations. Guideline-concordant prescribing was not significantly different between remote and face-to-face consultations for patients with sinusitis, but conflicting results were found for patients with acute respiratory infections. Mixed evidence was found for follow-up visit rates after remote and face-to-face consultations.

We concluded that there is insufficient evidence to confidently conclude that remote consulting has a significant impact on antibiotic prescribing in primary care. However, studies indicating higher prescribing rates in remote consultations than in face-to-face consultations are a concern. Further well-conducted studies are needed to inform safe and appropriate implementation of remote consulting to ensure that there is no unintended impact on antimicrobial resistance.

DOI: https://doi.org/10.2196/23482

Maximising the impact of social prescribing on population health in the era of COVID-19

Our new paper in the Journal of the Royal Society of Medicine discusses social prescribing, the process of referring people to non-clinical community services; such as exercise classes and welfare advice, with the aim of improving mental, physical and social wellbeing.

Social prescribing has been increasingly adopted across high-income countries including the UK, United States of America, Canada and Finland. The UK’s Department of Health first introduced the term ‘social prescribing’ in 2006 to promote good health and independence, especially for people with long-term conditions. Over a decade later, in 2019, NHS England committed to funding social prescribing through link workers. Link workers receive referrals, mainly from general practitioners, and are attached to primary care networks with populations of 30–50,000 people.

In the paper, we examine the impact of different social prescribing schemes in England, from a population health perspective, that focus on individuals, communities or a combination of both. We examine the opportunities to maximise social prescribing’s impact on population health, in the era of COVID-19, by realigning social prescribing to a household model that reflects principles of universality, comprehensiveness and integration.

The impact of COVID-19 on academic primary care and public health

The COVID-19 pandemic has had a dramatic effect on people’s lives globally. For academics working in fields such as primary care and public health, the pandemic led to major changes in professional roles as I discuss in an article published in the JRSM. Universities across the United Kingdom closed their campuses in March 2020 and switched to remote working. Staff began to work from home and teaching of students moved online. University staff rapidly had to put in place systems for teaching, monitoring and assessing students remotely. For many universities, these changes will be in place until the end of 2020, with no return to a more normal mode of working until January 2021 at the earliest.

DOI: https://doi.org/10.1177/0141076820947053

Identifying naturally occurring communities of NHS primary care providers

Primary Care Networks (PCNs) are a new organisational hierarchy with wide-ranging responsibilities introduced in the National Health Service (NHS) Long Term Plan. The vision is that PCNs should represent ‘natural’ communities of general practices (GP practices) collaborating at scale and covering a geography that fits well with practices, other healthcare providers and local communities. Our study published in BMJ Open aims to identify natural communities of GP practices based on patient registration patterns using Markov Multiscale Community Detection, an unsupervised network-based clustering technique to create catchments for these communities. With PCNs expected to take a role in population health management and with community providers expected to reconfigure around them, it is vital to recognise how PCNs represent their communities. Our method may be used by policymakers to understand the populations and geography shared between networks.

DOI: 10.1136/bmjopen-2019-036504

Impact of GP gatekeeping on quality of care, health outcomes, health care use, and spending

In many health systems, primary care physicians (sometimes referred to as general practitioners or family physicians) regulate access to specialist medical services and investigations. This process is sometimes described as “gatekeeping” and is a response to a shortage of specialists and a need to control healthcare spending. In gatekeeping systems, patients are required to visit a GP or primary care physician to authorise access to specialty care. However, the effectiveness of gatekeeping remains unclear.

In a systematic review published in the British Journal of General Practice, we examined the impact of gatekeeping on areas such as the quality of health care, healthcare spending and use, and health-related and patient-related outcomes.

We found an an association between gatekeeping and better quality of care, especially in terms of preventive care, and appropriate referral for specialty care and investigation. However, we found one study that reported unfavourable outcomes of patients with cancer under gatekeeping.

Gatekeeping resulted in fewer hospitalisations and lower specialist use, but also led to more primary care visits. Gatekeeping may also lead to lower healthcare use and expenditure. Primary care clinicians have conflicting views on gatekeeping, whereas patients are often less satisfied with gatekeeping schemes, preferring health systems where they have direct access to specialists.

As with many areas of health policy, the impact of gatekeeping on key health system metrics needs further investigation to help devise more efficient and equitable health systems that improve health outcomes and lead to high patient satisfaction whilst at the same time, keeping spending on health services at sustainable levels.

Is it getting easier to obtain antibiotics in the UK?

In the UK, antibiotics are, with very few exceptions, only prescribable by doctors or other health professionals with prescribing qualifications. This has meant that, until recently, access to antibiotics has been possible only through face-to-face medical assessment in primary or secondary care, providing a significant disincentive to seeking antibiotics unnecessarily.

Inappropriate prescribing of antibiotics in UK primary care remains of concern, but antimicrobial stewardship initiatives are having a measurable effect, with prescribing rates falling in response to interventions. However, novel routes to obtaining antibiotics, associated with either a lower threshold for prescribing or issuing of antibiotics without medical assessment, undermine these strategies and are likely to increase inappropriate use.

These issues are discussed further in an article published in the British Journal of General Practice.

Integrating a nationally scaled workforce of community health workers in primary care

Increasing workload, a reduced percentage of the budget and workforce retention and recruitment problems challenge the capacity of available general practitioners in the UK NHS. Consequently, patients’ ability to obtain general practitioner appointments has declined. Political pressure to improve access has been accompanied by promises of increased general practitioner numbers, but with a reported fall in 2016–2017,5 it remains unclear how this will be achieved. Meanwhile, financial constraints have also led to the loss of some community-based health services, such as district nursing and fragmentation of others.

In a study published in the Journal of the Royal Society of Medicine, we examined whether the systematic deployment of community health workers in the NHS could help address current problems of fragmentation and inefficiency, while improving clinical outcomes through improved uptake of appropriate services.

Conservative modelling suggested that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workers could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease.

We concluded that the integration of community health workers at scale in NHS primary care could represent a timely and relatively rapidly implemented approach to the workload crisis. Chronic disease management, cancer screening and MMR immunisation uptake provide examples of potential benefits; there is a need for formal piloting to establish the impact of community health workers in NHS primary care.

DOI: https://doi.org/10.1177/0141076818803443

Patients value the quality of care they receive from their GP over extended access

In recent years, the NHS has invested in ‘extended hours’ schemes, whereby general practice are encourage to open beyond their contracted hours of 8am to 6.30pm Monday to Friday. In a study published in the British Journal of General Practice, we examined associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours using data from the General Practice Patient Survey.

We found that patient experience of making appointments and satisfaction with opening hours were only modestly associated with overall experience. Patient satisfaction was most strongly associated with GP interpersonal quality of care

We concluded that policymakers in England should not assume that recent policies to improve access will result in large improvements in patients’ overall experience of general practice.

The article was covered by the medical magazine Pulse.

The impact of private online video consulting in primary care

Workforce and resource pressures in the UK National Health Service (NHS) mean that it is currently unable to meet patients’ expectations of access to primary care. In an era of near-instant electronic communication, with mobile online access available for most shopping and banking services, many people expect similar convenience in healthcare. Consequently, increasing numbers of web-based and smartphone apps now offer same-day ‘virtual consulting’ in the form of Internet video conferencing with private general practitioners.

While affordable and accessible private primary care may be attractive to many patients, the existence of these services raises several questions. A particular concern, given continued development of antimicrobial resistance, is that some companies appear to use ease of access to treatment with antibiotics as an advertising strategy. We examine online video consulting with private general practitioners in the UK, considering its potential impact on patients and the National Health Service, and its particular relevance to antimicrobial stewardship in an article published in the Journal of the Royal Society of Medicine.

Questions remain about the safety of online consulting and of the working practices of some private companies, and appropriate regulation is essential to ensuring that these services offer safe and effective care to patients. This will require a carefully tailored approach on the part of regulators such as the Care Quality Commission. For example, it has not been necessary to develop standards on advertising when assessing National Health Service general practices, but this will be essential in monitoring the actions of private online general practice services.

The article was covered by a number of media outlets including PulseGP and the Sun.

https://doi.org/10.1177/0141076818761383

Clinical pharmacists in primary care: a safe solution to the workforce crisis?

In a paper published in the Journal of the Royal Society of Medicine, we discuss the role that clinical pharmacists could play in primary care.

Primary care in the United Kingdom’s NHS is in crisis. Systematic underfunding, with specific neglect of primary care compared to other clinical specialties, has combined with ever-rising demand and administrative workload to place a now dwindling workforce under unsustainable pressure.

A major factor in the growing workload in primary care is prescribing. An aging population and higher prevalence of chronic diseases is leading to increased case complexity and polypharmacy, and consequently greater potential for prescribing errors. Nearly 5% of all prescriptions in general practices in England have prescribing or monitoring errors, while in some areas up to half of the prescriptions are prone to error. Although most errors are of mild or moderate severity, they can be life-changing for patients and costly for healthcare systems, accounting for around 3.7% of preventable hospital admissions.

Workload and time pressures exacerbate prescribing errors. Concerns about workload and access in primary care have led the UK Government to pledge increases in the general practitioner workforce, but general practitioners take at least 10 years to train and declining numbers of medical graduates internationally suggests a limited pool for recruitment. In this article, we discuss integration of clinical pharmacists in general practices as a potential solution to these problems.

While the pool of general practitioners is limited, the number of pharmacists is increasing. Pharmacists undertake shorter training than general practitioners, with four years undergraduate degree followed by one year of pre-registration experience. While the role of pharmacists has expanded beyond dispensing of medications and now involves provision of several other aspects of patient care, their knowledge and expertise is often under-utilised. Making use of their expertise in medication management, pharmacists could perform a variety of tasks in primary care, improving patient safety and clinical outcomes through optimised medication use, and potentially alleviating workload, freeing up general practitioners to deal with more complex cases and reducing waiting times for appointments.

Pharmacists have been working in primary care teams for some time in non-patient-facing roles. Areas in which they support practices include auditing for performance targets, implementation of enhanced services, preparation for inspections by the Care Quality Commission, training staff in repeat prescribing and providing medicines information for other clinicians. However, these roles currently vary from practice to practice. The widespread integration of pharmacists in both patient-facing and non-patient-facing roles therefore has the potential to have impact in three key areas: safety of prescribing; improved health outcomes; and access to primary care through reduction of general practitioner workload

DOI: https://doi.org/10.1177/0141076818756618