Tag: Primary Care

How can we improve the quality of data collected in general practice?

The primary purpose of general practice electronic health records (EHRs) is to help staff deliver patient care. In an article published in the British Medical Journal, Lara Shemtob, Thomas Beaney, John Norton and I discuss the need for the general practice staff entering data in electronic health records to be more connected to those using the information in areas such as healthcare planning, research and quality improvement.

Documentation facilitates continuity of care and allows symptoms to be tracked over time. Most information is entered into the electronic record as unstructured free text, particularly during time pressed consultations. Although free text provides a mostly adequate record of what has taken place in clinical encounters, it is less useful than structured data for NHS management, quality improvement, and research. Furthermore, free text cannot be used to populate problem lists, calculate risk scores, or feed into clinical management prompts in electronic records, all of which facilitate delivery of appropriate care to patients.

Creating high quality structured data that can be used for health service planning, quality improvement, or research requires clinical coding systems that are confusing to many clinicians. For example, coding can seem rigid in ascribing concrete labels to symptoms that may be evolving or of diagnostic uncertainty. It is time consuming for staff to process external inputs to the electronic record, such as letters from secondary care, and if this is done by administrators, comprehension of clinical information may be a further barrier to high quality structured data entry.

The content of digital communications such as text messages from patients to clinicians, emails, and e-consultations may also need to be converted to structured data, even if the communication exists in the electronic health record. This all represents additional work for clinicians with seemingly little direct incentive for patients. As frontline clinical staff are usually not involved in the secondary uses of data, such as health service development and planning, they may not consider the extra work a priority.

To maximise the potential of routinely collected data, we need to connect those entering the data with those using them, also incorporating patients as key beneficiaries. This requires adopting a learning health systems approach to improving health outcomes, which involves patients and clinicians working with researchers to deliver evidence based change, and making better use of existing technology to improve standardised data input while delivering care.

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Data from primary care played a key role in the UK’s Covid-19 pandemic response as shown in this slide which uses data from a range of sources – including general practice records – to examine the impact of vaccination on hospital admissions for Covid-19 in England.

Arguments for and against user fees for NHS primary care in England

There has been considerable recent debate about charging for GP appointments after comments from two former UK health secretaries, Kenneth Clarke and Sajid Javid, elicited strong responses both for and against user fees. Let’s try to put aside ideology and emotion and look objectively at the evidence and arguments around user fees in NHS primary care.

Debates over NHS user fees are not new. In 1951, Hugh Gaitskell introduced charges for prescriptions, spectacles, and dentures. Aneurin Bevan, minister for labour and architect of the NHS, resigned in protest at this abandonment of the principle of NHS care being free at the point of need. Many developed countries already charge users to access primary care services, often through a flat-rate co-payment. However, there is a lack of evidence about the impact of such fees on access to healthcare, health inequalities, and clinical outcomes. A key study on the impact of user fees in a high income country (the RAND Health Insurance Experiment) is now nearly 40 years old.

User fees should theoretically encourage patients to act prudently and so reduce “unnecessary” or “inappropriate” use of healthcare. Some European countries with user fees for primary care have indeed seen lower rates of healthcare utilisation. But this theory is based on the assumption that patients can safely and effectively distinguish between necessary and unnecessary care. In reality, preventive care and chronic disease management are both likely to decline when fees are in place, with patients often delaying presentation until costly medical crises occur.

Expectations about what the UK NHS should offer are already high among the public, and user fees may further increase expectation of a “return on investment.” Doctors may feel pressure to provide prescriptions and referrals, or carry out investigations, to satisfy patients who have paid to see them. User fees may also result in patients hoarding health problems, with clinicians expected to tackle more health concerns in the typical 10-15 minute appointment in general practice. Flat-rate user fees might also introduce a financial barrier to healthcare access for people with a low income, potentially widening health inequalities.

The highest users of primary care, such as women seeking maternity care, and those aged under 5 or over 65 years, are also among the group that would probably be exempt from user fees. If people with a low income are also exempted from fees, we may see little reduction in GP workload, and only modest additional revenues for the NHS—particularly when offset against the costs of collecting fees, including chasing patients for any unpaid fees.

Wealthier patients, when asked to pay for NHS GP appointments, may opt for private primary care instead, further increasing health inequalities and leading to the fragmentation of care. Such an environment could cause private primary care services to expand, increasing shortages of NHS GPs if more GPs choose to work in the private sector.

The collection of user fees would require new billing and debt collection systems across all NHS general practices. To safeguard vulnerable people it would be necessary to create exemptions, which would reduce revenue and further add to administrative costs. After exemptions, user fees would probably only be collected from a relatively small section of the population. For example, around 90% of NHS primary care prescriptions in England are dispensed free of charge and revenues from prescription charges cover only a small percentage of the actual cost of NHS drugs.

User fees may also lead to false economies if they deter people from accessing primary care when they should, resulting in costly delayed diagnoses (for example, for cancer), or lead people to seek care only for acute problems, deprioritising important preventive and chronic care.

User fees will also be ineffective if they divert costs to other parts of the NHS such as accident and emergency departments or urgent care centres. In the USA, for example, user fees have led to “offsetting” of costs, with increased hospital admissions and use of acute mental health services. Patients may therefore choose to use services that are “free” to the user but expensive to the system, such as emergency care. A coherent policy would require simultaneous setting of fees in related areas of the NHS—for example, charging a fee for attending A&E.

UK residents benefit from a high level of financial protection from the costs of illness. Accustomed to free primary care for many decades, the public is likely to resist such fees strongly. As a result, any political party that advocated NHS user fees may pay a high price at a general election.

Valid arguments exist for and against introducing primary care user fees. User fees are promoted by some commentators as a remedy to current NHS challenges in areas such as funding and workload. Yet primary care workload and NHS deficits are also symptoms of deeper problems, such as shortages of clinical staff and reactive, fragmented care. Consequently, user fees by themselves won’t be the solution to problems that have proven intractable for the NHS to solve.

We do, however, need to look at what services we expect NHS general practices to provide and how we fund these services. This will include reviewing the current employment models of NHS GPs. If governments in the UK do not want to fund NHS GP services adequately, user fees of some kind (perhaps for “add-on” but not for core primary care services) or two-tier primary healthcare may be inevitable outcomes.

Source: Azeem Majeed. Let’s look dispassionately at the arguments for and against user fees for NHS primary care in England. https://www.bmj.com/content/380/bmj.p303

Update for Primary Care Clinical Team 19 January 2023

1. Covid-19 statistics update

After a peak in December, Covid-19 cases, hospital admissions and deaths have begun to decline in January 2023. We are though likely to see further waves of infection later in the year.

2. Covid-19 vaccine boosters

Uptake of Covid-19 boosters has plateaued at a lower level than we hoped for. In England, around 64.4% of people aged 50 and over have received a booster in the current campaign. In Lambeth, only 40% of people aged 50 and over have received a Covid-19 booster, well below the national average. Pleas encourage patients to attend for a booster if they are eligible.

3. Covid-19 treatments

Some people at highest risk of becoming seriously ill from COVID-19 are eligible for antiviral treatments on the NHS. These include some patients with cancer, blood conditions, kidney disease, liver disease and autoimmune conditions, among others.  GP reception staff must arrange an appointment with the clinical team if a patient calls and says they are eligible for these treatments, have tested positive for COVID-19 and have not been contacted about treatment.

My view is that the NHS England treatment pathway is flawed. Asking patients to contact their general practice delays the start of treatment and adds to GP workload. Patients should have been asked to contact their local CMDU directly if they have not been contacted about treatment after a positive Covid-19 test. Any failure by the local CMDU to contact a patient should be seen as an SEA.

 4. Influenza

The latest UKHSA report shows that influenza admissions in London have started to fall from their peak in February. See recent Evening Standard article. https://www.standard.co.uk/news/london/london-past-peak-flu-wave-nhs-azeem-majeed-b1053535.html

We were expecting a larger flu wave in the Winter of 2022-23 because of the greater social missing this winter and the low levels of flu over the previous 2 years.

5.  NHS pressures

The NHS in England has experienced exceptionally high pressures in recent weeks, leading to the Prime Minister holding an emergency NHS summit on Saturday 7 January. We await the outcome of the summit. Strike action is adding to NHS pressures. We need to consider a team how we can support our patients and manage workload.

Transforming health through the metaverse

A real change is on the horizon. In October 2021, Facebook announced that it would rebrand itself as ‘Meta’, and this generated high levels of public interest in the metaverse for the first time. Definitions for the metaverse vary and there is still much uncertainty in its eventual future manifestation. It is perhaps best defined as a fully immersive parallel digital reality where users will be able to interact at a scale previously unimagined.1 The advent of the metaverse could have transformational impact on every aspect of human life, from our social interactions to what we ascribe real value to. Just as the Internet has completely transformed health, the metaverse will redefine virtual and physical possibilities in health.2 This will have major implications for our health and for healthcare delivery. The coming of age of the metaverse is in due largely to the maturation of technological advances in artificial intelligence and devices that enable the delivery of mixed, augmented and virtual reality, along with cryptography, the catalyst behind web3, and increased computing power.

Read the full article in the Journal of the Royal Society of Medicine.

Primary care update on Group A Streptococcal infections in the UK

There has been an increase Group A Streptococcal (GAS) infections in recent months, which has led to at least 8 deaths in children. Although GAS rates are higher than expected for this time of year, they have been higher at periods over the last decade. GAS causes a range of infections including Scarlet Fever and also more severe invasive disease.

For more information on management, see: Scarlet fever: a guide for general practitioners. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649319/
The Centor score can be used to assess the probability of an illness being GAS pharyngitis: Tonsillar exudates, tender anterior cervical adenopathy, absence of cough, history of fever (>38 °C). Penicillin V (or Amoxicillin) is the preferred treatment unless contra-indicated in which case an alternative such as a cephalosporin or clarithromycin can be given.

Scarlet Fever and invasive GAS disease are notifiable and should be reported to the local health protection unit. Contacts (although at higher risk of GAS infection) do not generally need antibiotics unless symptomatic. See contact tracing flowchart for details. Health protection teams are responsible for contact tracing.

This guidance was updated in 2008 and may change again.
https://www.gov.uk/government/publications/invasive-group-a-streptococcal-disease-managing-community-contacts

Antibiotics should only be administered:
1. To mother and baby if either develops invasive group A streptococcal disease in the neonatal period (first 28 days of life);
2. To close contacts if they have symptoms suggestive of localised Group A streptococcal infection, i.e. sore throat, fever, skin infection;
3. To the entire household if there are two or more cases of invasive group A streptococcal disease within a 30 day time period.

Oral Penicillin V is the drug of first choice where chemoprophylaxis is indicated. Azithromycin is a suitable alternative for those allergic to penicillin. Some areas of England are now reporting shortages of liquid antibiotics.

Developing a shared definition of self-driven healthcare

Witing in the Journal of the Royal Society of Medicine, myself, Austen El-Osta and Chris Rowe set out a vision for building sustainable, self-driven healthcare spanning primary care, secondary care and the wider health and social care system has been set out by medical innovators. Self-driven healthcare (SDH) is an umbrella term introduced by Innovate UK, the UK’s national innovation agency, to conceptualise aspects of healthcare delivery that can support people in becoming more engaged in managing their own health and wellbeing, rather than being passive receivers of healthcare.

In our paper, we describe an SDH ecosystem that supports individuals to take more ownership of their health and wellbeing and in recording their own data (e.g. weight, blood pressure) using a phone app, tablet, computer or Bluetooth device. This self-generated data would then be uploaded onto a secure online SDH portal which holds all their health records, including those generated in the wider healthcare system.

Individuals would also enter other data such as what medication they had taken that day, the food they had eaten or the exercise they had done. They may even have a range of other devices that automatically record and upload useful information, such as environmental data about local air quality that day. A personalised dashboard would automatically present the user with their ‘digital twin’ and the portal may also be enabled to routinely offered insights and actionable advice, including microlearning and behaviour change interventions and a holistic picture of the person’s overall health and wellbeing status.

The SDH approach must create better access to all sections of the community rather than just wealthier and more technically literate individuals. It is also crucial that the SDH movement does not exacerbate inequalities due to the digital divide. How SDH is adopted in the future is very important, especially when it is applied to help enhance the consumer health system by trying to link it effectively with state-funded NHS health and social care systems. It will be important to determine if these online environments will be provided by expanding the NHS App, for example, or by commercial companies.

Multidisciplinary Team Meetings to Manage Patients with Multimorbidity in Primary Care

Our new paper in the International Journal of Integrated Care reviews the role of multidisciplinary team (MDT) meetings in the management of multimorbidity in primary care. MDTs bring together professionals to work together to improve health outcomes for patients. MDT meetings are often recommended as a critical aspect of integrated care in guidance and opinion pieces, but it is not clear how and to what extent their use improves outcomes for patients with multimorbidity. Our review aimed to fill this knowledge gap.

We found limited evidence that supports the implementation of MDT meetings in primary care settings for individuals with multimorbidity. There were also substantial problems with the methodological rigour of previous studies on MDT meetings in primary care. Although MDT meeting are a key strategy for delivering comprehensive integrated care, there is a lack of evidence concerning the efficacy of MDT meetings in primary care. The complexity of interventions meant that causality cannot be attributed to the MDT meeting alone.

There is an urgent need generate more evidence about MDT meetings in primary care. Future research should focus on a broader set of participant characteristics, contextual adaptation, and innovation. Decision makers and clinicians should also take advantage of the recent technological progress in healthcare.

Why is FIT important for people with lower gastrointestinal symptoms?

If you consult your doctor about bowel symptoms, they may speak about getting FIT. What is FIT? In this context, it is nothing to do with exercise or how far you can run. FIT stands for faecal immunochemical test, which aims to detect blood in your faeces. The test is highly sensitive.

People with lower bowel symptoms such as a change in their bowel habits will understandably be concerned about the possibility of bowel cancer. The risk of colorectal cancer in people with a negative FIT, a normal examination and normal full blood count is <0.1%. This is lower than the general population risk of colorectal cancer. So this combination of clinical findings allows your doctor to conclude that you are very unlikely to have bowel cancer. However, many people with lower GI symptoms still do not undergo FIT before referral to a specialist.

Patients with a FIT of fHb <10μg Hb/g, a normal full blood count, and no ongoing clinical concerns do not need to be referred on a lower GI urgent cancer pathway but can be managed in primary care or referred on an alternative pathway with suitable safety netting if symptoms change. FIT can improve patient management. By fully implementing the use of FIT in people with lower GI symptoms in primary care, we can spare patients unnecessary colonoscopies, releasing capacity to ensure the most urgent symptomatic patients are seen more quickly in specialist clinics.

There are some patients for whom FIT is not suitable, such as those with iron deficiency anaemia, a rectal or anal mass, or anal ulceration. See below for further guidance on the use of FIT in people with lower GI symptoms.

https://www.england.nhs.uk/wp-content/uploads/2022/10/B2005_i_Using-faecal-immunochemical-testing-lower-gastrointestinal-pathway_primary-care-letter.pdf

https://www.bsg.org.uk/clinical-resource/faecal-immunochemical-testing-fit-in-patients-with-signs-or-symptoms-of-suspected-colorectal-cancer-crc-a-joint-guideline-from-the-acpgbi-and-the-bsg/

Why we need to put an end to the GANFYD culture in the UK

One of the causes of increased workload in general practice are the many requests that doctors get for letters from patients or from external organisations. It’s now so common that doctors have coined a term for it: GANFYD – Get A Note From Your Doctor.

It’s seems that large sections of society can’t function without these “letters from doctors”. Instead of using common sense or employing their own clinical advisers, external organisations make repeated requests to NHS doctors for letters which are not at all needed.

Often the worst offenders come from the public sector – e.g. universities who seem to look upon NHS general practice as a source of free occupational health advice for their students. Universities never – of course – offer to pay for this advice they get from NHS GPs.

Instead, university requests will come with a mealy-mouthed statement that any fee is the responsibility of the student. Like doctors are going to impose heavy fees on impoverished students who already have large debts and are who are often living in poverty.

Local government and schools are other frequent offenders, requesting letters for issues they could easily resolve themselves using some common sense. And perhaps surprisingly, the NHS is also a frequent offender (you would think that NHS Trusts would know better).

What’s the solution? I have concluded that to address the GANFYD problem, we need to remember the adage “money talks while bullshit walks”. But don’t charge patients. Change NHS regulations so the (suitably large fee) is the responsibility of the organisation making the request.

The NHS is under great pressure and we urgently need to do everything we can to reduce unnecessary work in the NHS so that NHS staff can focus on clinical work.

General practitioner perceptions of using virtual primary care during the COVID-19 pandemic

Whether it be a simple telephone call or more sophisticated video conferencing systems, virtual care tools have been in use in primary care settings worldwide in one form or another throughout the past two decades. Over time, these tools have grown in availability, matured in their capabilities, but played a largely supportive role as an alternative option to traditional face-to-face consultations. This all changed in early 2020 with the onset of the COVID_19 pandemic.

The COVID-19 pandemic presented a unique opportunity globally which put virtual care tools at the forefront of primary care delivery. The need for social distancing to limit disease transmission resulted in virtual care tools becoming the primary means with which to continue providing primary care services. Hence, our study’s goal was to capture the spectrum of GP experiences using virtual care tools during the initial months of the pandemic so as to better understand the perceived benefits and challenges, and explore what changes are needed to allow them to reach their fullest potential.

We carried out a global study to investigate this further, published in the journal PLOS Digital Health. We received 1,605 responses from 20 countries globally. Our results demonstrated that virtual care tools were beneficial in limiting COVID-19 transmission, improved convenience when communicating with patients, and encouraged the further adoption of virtual care tools in primary care. Challenges included patients’ preferences for face-to-face consultations, digital exclusion of certain populations, diagnostic challenges associated with the inability to perform physical examinations, and their general unsuitability for certain types of consultations. Practical challenges such as higher workloads, payment issues, and technical difficulties were also reported.

Learning from this global natural experiment is critical to both updating existing and introducing new health technology policies concerning virtual primary care. Doing so will be imperative to supporting and promoting the better use of these novel technologies in our evolving healthcare milieu.

DOI: https://doi.org/10.1371/journal.pdig.0000029