Tag: Primary Care

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.


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

Seven-day access to NHS primary care: how does England compare with other European countries?

It is often assumed that providing easier access to community-based general practice during evenings and weekends can reduce demand for emergency and other unscheduled care services, promoting more appropriate care and reducing the costs associated with expensive hospital-based treatment. For example, in England’s NHS there is political pressure to expand general practice surgeries’ opening hours to progress towards a ‘seven-day NHS’.

When considering extension of primary care opening hours in England, it is useful to compare primary care access across other countries in the European Union. Despite differences in healthcare commissioning and funding, European countries face comparable challenges such as ageing populations and increases in chronic conditions and mental health problems, all of particular relevance to primary care.  In a paper published in the Journal of the Royal Society of Medicine, we examined England’s current in-hours general practice services relative to those of European countries in order to better contextualise the debate on extending general practice opening hours.

We found that standard opening hours in England already exceed those of most other European countries, and patients in the UK are more satisfied with out-of-hours access to general practice than patients in many other European countries. Achieving easier access to primary care services seven days per week would require significant investment, and must compete with other NHS priorities; politically attractive priorities should not to have an undue influence in shaping resource allocation.

The existence of true patient demand for extension of general practice opening hours in England is not yet fully established and evidence for a correlation between increasing in-hours provision and decreased emergency department use is inconclusive. Furthermore, the demand for services likely varies based on local demographics and disease burden; if general practice opening hours were to be extended, those regions with the highest demand for care should be prioritised.

Hence, we suggest that policy-makers in England should focus on improving access to GP appointments during normal opening hours, instead of spending scarce NHS resources on very poor value for money extended opening hours schemes.


Extending GP opening hours will not ease the rising burden on A&E departments

A study published in the journal BMJ Quality and Safety concluded that extending GP opening hours will not ease the rising burden on Accident and Emergency departments. The observational study was led by Imperial College London. Lead author Dr Thomas Cowling from Imperial College’s Department of Primary Care and Public Health and colleagues compared patients’ experiences of GP surgeries with the number of Accident and Emergency visits in their areas in England from 2011-2012 to 2013-2014. They examined reports from NHS England’s annual GP Patient Survey, and included patients registered to 8,124 GP surgeries.

We measured levels of patient satisfaction using three factors: the ease of making an appointment, opening hours, and overall experience. They then matched these responses with A&E departments in their area to observe any correlation with the number of visits to A&E. Overall, areas where patients were happier with the ease of making appointments, which could be for example by using online booking systems, saw slightly fewer visits to Accident and Emergency departments. However, satisfaction with surgery opening hours and overall patient experience seemed to have no impact on Accident and Emergency visit rates.

The study suggests that better satisfaction with GP hours, for example because of extended opening hours, does not affect the number of visits made to A&E in their geographical area. However, making the appointment booking process easier for patients was associated with slightly fewer Accident and Emergency visits in that area. Our research supports finding alternative options for easing the burden on Accident and Emergency departments, and casts doubt on the Government’s proposals to extend GP surgery hours to ease the burden on Accident and Emergency departments.

We measured satisfaction with hours without linking explicitly them to daytime weekday or evening and weekend appointment availability. We hypothesised that although weekend and evening appointments are convenient for healthy, working aged adults, those who are likely to need medical attention more urgently are older people or those who are chronically ill and not currently working full time.

Senior author Professor Azeem Majeed from Imperial’s School of Public health, who is a practising GP, said: “The government must find alternative ways to handle current pressures on Accident and Emergency departments. This could include for example improving access to GP appointments during normal opening hours rather than spending scarce NHS resources on extended opening schemes.”

Dr Cowling, also from Imperial’s School of Public Health, said: “It makes sense to think that extending GP hours will ease the burden on other NHS services, but our study suggests this might not be the case with Accident and Emergency.”

The study was reported in a number of media outlets including the TimesBelfast TelegraphOnMedicaPulse and Eureka Alert.

Patients are more satisfied with general practices managed by GP partners than those managed by companies.

General practices in England are independent businesses that are contracted to provide primary care for specified populations. Most are owned by general practitioners, but many types of organisation are now eligible to deliver these services. In a study published in the Journal of the Royal Society of Medicine, we examined the association between patient experience and the contract type of general practices in England, distinguishing limited companies from other practices.

We analysed data from the English General Practice Patient Survey 2013–2014 (July to September 2013 and January to March 2014). Patients were eligible for inclusion in the survey if they had a valid National Health Service number, had been registered with a general practice for six months or more, and were aged 18 years or over. All general practices in England with eligible patients were included in the survey (n = 8017).

Patients registered to general practices owned by limited companies reported worse experiences of their care than patients registered to other practices on average. This applied to practices recorded as limited companies in routine contract data and to practices owned by large organisations. The sizes of the differences in experience varied from moderate to large across four outcome measures and were largest for the frequency of consulting a preferred doctor. Limited company ownership of general practices is uncommon in England. Patient experience was not consistently associated with the contract type for practices not recorded as limited companies. Across all contract and ownership types, patients generally reported positive experiences of their general practices.

Although our results suggest that limited companies provide worse patient experiences on average, some practices owned by these companies provide a good experience; others provide the opposite. It is the responsibility of commissioners, regulators, clinicians and owners to guarantee that individual practices meet expected standards while ensuring that care quality is not systematically associated with the ownership. Commissioners also need to ensure that contracts offer good value for money, more so at a time when the National Health Service is under severe financial pressure.

What role should general practitioners play in a modern health system?

Health systems across the world are faced with many challenges – such as rising patient expectations, increased workload, ageing populations, and an increased number of people with long-term conditions. At the same time, health systems also face significant financial problems. Consequently, governments, other funders of healthcare and patients expect more from their doctors without necessarily offering them additional resources.

As the first point of contact with patients, what role should general practitioners (in some countries, referred to as primary care physicians or family practitioners) play in meeting these challenges? General practitioners (GPs) have to deal daily with large numbers of patients, cope with a very wide range of clinical problems, meet performance targets, and provide continuity of care. At the same time, GPs also have to provide easy access to health services, show they are addressing issues such as the rise of antimicrobial resistance; and play a public health role in addressing unhealthy lifestyles and improving the uptake of preventive programmes such as screening and immunization.

Can GPs meet all these challenges? What support do GPs need to meet them? Could more be done to support GPs by non-medical health professionals? What do patients expect from their GPs? Does the training and continuous professional development of GPs need to change? How do we make use of staff from other professional groups such as nurses, pharmacist and healthcare assistants? How should we fund primary care services? These are important questions that we will aim to examine in future work at Imperial College London.

How do I encourage a patient to see a pharmacist?

We are employing a pharmacist to help with treatment reviews and to see minor acute illness but we are finding resistance from some patients to seeing him, with receptionists reporting that patients are requesting appointments with ‘a proper doctor’ instead. How do we respond?

Pharmacists offer many potential benefits to general practices. They can free up doctors’ time, deliver cost-savings to the NHS through more rational prescribing, and improve the quality of patient care. For example, pharmacists can improve patients’ understanding of their medication and their adherence to their drug regime. An increasing number of general practices are now using pharmacists and their role will be further expanded when the GP Forward View is implemented. However, some patients may be unwilling to see a pharmacist and insist on seeing a doctor.

To overcome this resistance, it is essential that all staff are briefed about the role of the pharmacist and what to say to patients who express concerns about seeing him. This process should start before the pharmacist is in post, as should a discussion of the role of the pharmacist with the practice’s Patient Participation Group. The staff briefing should reinforce points such as pharmacists being highly trained professionals; pharmacists who work in primary care will have undergone additional training such as an Independent Prescribing Course; by taking on work such as medication reviews and the management of minor illnesses, pharmacists can allow doctors to spend more time with complex patients; and that pharmacists can always seek advice from a doctor when needed. You could also include this information on your practice website, in any induction pack given to new patients and in your practice newsletter.

If some patients remain reluctant to see a pharmacist, they could speak to a more senior member of the practice team such as the practice manager or deputy manager. If however a patient remains unconvinced by these explanations, I would let them see a doctor. Attitudes towards pharmacists will change over time and patients will eventually come to understand that they are highly skilled professionals who have a valuable role to play in primary care.

You can read my article, and also those of some other doctors, in Pulse.

WHO Europe Primary Health Care Advisory Group

Professor Salman Rawaf was appointed by WHO Europe as a member of the newly formed Advisory Group on Primary Health Care. The first meeting of all Members was attended by the Regional Director Dr Zsuzanna Jakab and Kazakhstan’s Minister of Health, Dr Alexey Tsoy. Professor Rawaf gave a presentation on integration of public health and primary care services and highlighted the role of Healthy Living Centres in the UK. He also described some possible models for the integration using the experience of countries around the globe. The WHO European Centre for Primary Health is leading the work across the 53 member states of WHO Europe.

Rethinking primary care’s gatekeeper role

Gatekeeping is the term used to describe the role of primary care physicians or general practitioners (GPs) in authorising access to specialist services and and diagnostic tests. Gatekeeping has important influences on service utilisation, health outcomes, healthcare costs, and patient satisfaction. In an article published in the British Medical Journal, we discuss the role of gatekeeping in modern health systems.

In the UK access to NHS and private specialists is generally possible only after a referral from a GP. Gatekeeping was developed as a response to a shortage of specialists and a desire to control healthcare spending and has been an accepted practice in the UK for many years. The NHS is under considerable pressure to use its resources efficiently, and GPs have helped the NHS to achieve this goal through managing a large proportion of NHS workload in primary care. However, GPs in the UK now find themselves under considerable workload pressures. In an 11-country survey of primary care physicians, it was GPs in the UK who had the shortest consultation lengths and were the most stressed. Could direct access to some NHS services help reduce GP workload and facilitate greater patient choice?

Internationally, there is a large variation in the role of primary care physicians in “gatekeeping”. In many countries, patients can access specialist services directly without a referral from a primary care physician (sometimes with a co-payment). Although it is often assumed that gatekeeping will help control healthcare costs, there is little association between the strength of gatekeeping in countries and the proportion of GDP spent on healthcare. Some countries with weak gatekeeping spend a relatively small proportion of GDP on healthcare (e.g. Singapore).

Within countries, there can also be differences in gatekeeping policies. In England, for example, there are large variations between clinical commissioning groups (CCGs) in policies for giving patients direct access to services. For example, some CCGs allow patients to have direct access to physiotherapy services.

In the article, we look at the pros and cons of gatekeeping, describe gatekeeping policies in various countries, and highlight the need for more evidence to devise policy. We conclude that gatekeeping policies should be revisited to accommodate the government’s aim to modernise the NHS in terms of giving patients more choice and facilitate more collaborative work between GPs and specialists. At the same time, any relaxation of gatekeeping should be carefully evaluated to ensure the clinical and non-clinical benefits outweigh the costs.

Why we need workload-based funding for general practices in England

The NHS is currently aiming to develop a new capitation-based formula for funding general practices in England. My view is that a revised formula won’t address the fundamental problem with the current method of funding primary care: the disconnect between workload and funding. All the new formula will do – no matter how well-designed – is shuffle money between general practices. Some practices will gain substantial sums, some will lose substantial sums; but most practices will see no major changes in their funding.

Capitation-based formulas for general practices are therefore a 20th century solution that the government is trying to continue to use in the 21st century. We need to move away from a capitation-based funding model to one based on actual workload as well as on capitation. Under such a model, any work done by general practices – whether generated through government policy, patient demand or transfer of work from specialist settings into the community – would be paid for at its full cost. There would then be no need for any ‘funding formula’. The more work a practice did, the more it would get paid.

This is how primary care funded in many other developed countries and results in improved access to primary care services. Critics of workload-based funding for general practices might argue it would dramatically increase costs as well as being administratively complex to administer. However, the alternative is the continuation of current trends, with worsening access for patients to primary care services; and an exacerbation of GP recruitment and retention problems.

This blog was originally posed as a rapid response on the BMJ website.