Blog posts

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 Pulse, GP 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

We need a review of all sepsis deaths, not the conviction of health professionals, to improve the care of patients with sepsis

NHS England estimates that approximately 37 000 deaths a year are caused by sepsis.[1] This means that in the seven year period between 2011 and 2017, around 259 000 people died from sepsis in England. Only one of these deaths, that of Jack Adcock in Leicester in 2011, has resulted in the conviction of health professionals for manslaughter (Hadiza Bawa-Garba and Isabel Amaro).[2]

Sepsis can be difficult to diagnose, and delays and omissions in its diagnosis and treatment contribute to the high death rate. Even the former chair of the General Medical Council, Graham Catto, has admitted that he failed to diagnose sepsis in a timely manner, an error that contributed to a patient’s death.[3] Because of the problems diagnosing and treating sepsis, numerous initiatives have aimed to improve its management in both primary care and hospital settings. Details of one of the most recent of these initiatives were published by NHS England in September 2017.[4]

Given the scale of death from sepsis and the many delays and errors so often seen in its management, why were Bawa-Garba and Amaro convicted of gross negligence manslaughter? Was their management of Jack Adcock so different from the management of other cases of sepsis that resulted in death that they were justly convicted? Or were they involved in just one of many cases where suboptimal management of sepsis contributed to death? NICE guidance NG51 and Quality Standards QS161 have only recently set out the expectations of best practice in sepsis care—several years after Bawa-Garba and Amaro were charged.[5,6]

We need an objective review of sepsis deaths to identify the contribution of suboptimal management to the death and to recognise lessons for the future in a non-judgmental manner, not the prosecution of health professionals, if we are to improve clinical outcomes for patients with sepsis.

References
1. NHS England. Improving outcomes for patients with sepsis A cross system action plan. December 2015. https://www.england.nhs.uk/wp-content/uploads/2015/08/Sepsis-Action-Plan-23.12.15-v1.pdf
2. Ladher N, Godlee F. Criminalising doctors. BMJ2018;360:k479.doi:doi:10.1136/bmj.k479pmid:29419388
3. NHS National Patient Safety Agency. Medical Error. August 2005. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=61579
4. NHS England. Sepsis guidance implementation advice for adults. September 2017. https://www.england.nhs.uk/publication/sepsis-guidance-implementation-advice-for-adults/
5. National Institute for Health and Care Excellence. Sepsis: recognition, diagnosis and early management. NICE guidance NG51. July 2016. https://www.nice.org.uk/guidance/ng51
6. National Institute for Health and Care Excellence. Sepsis. Quality Standard 161. September 2017. https://www.nice.org.uk/guidance/qs161

DOI: https://doi.org/10.1136/bmj.k629

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.

https://doi.org/10.1177/0141076818755557

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 Times, Belfast Telegraph, OnMedica, Pulse and Eureka Alert.

Interested in our Integrated Clinical Apprenticeship? Read our FAQs

WHAT ARE MY MORNING COMMITMENTS?

Your Thursday morning and afternoon throughout your year 5 will be dedicated to the Integrated Clinical Apprenticeship. This has been negotiated with the Year 5 course leads and your Specialty supervisors for each firm. Attendance is mandatory for both morning and afternoon sessions. You will attend your allocated GP surgery on a time negotiated with your GP mentor. In the morning, you will see patients from your caseload, assessing their clinical needs and bringing yourself up to date with their secondary care contacts. You can then plan with your patient to attend any secondary care appointments in the coming weeks with your patients.  You may also see “ad hoc” patients from the surgery and, if relevant, add them to your caseload. There will be an opportunity to see other health professionals in the primary care team and assist in their daily activities.

WHAT IS MY PATIENT “CASELOAD”?

This is a group of about 12 patients (shared with your pair), recruited by your GP and you, who you will follow through the year, both in primary and secondary care. Depending on their clinical condition, you may not be required to follow them through the entire year, but other patients can be “picked up” through the year on an ad-hoc basis.

WHAT WILL I BE EXPECTED TO DO WITH MY PATIENTS?

You will be expected to see patients, assess them clinically, perform reviews (eg mental health and ante-natal reviews), manage your own appointments and home visits and perform investigations on your patients as required.

WHAT IF I FEEL I AM MISSING OUT ON FIRM OBLIGATIONS?

It will be up to you to decide whether some of the secondary care appointments will take precedence over commitments elsewhere in your firm. This will require discussion with your site leads as these arise. These negotiations are an important part of becoming a flexible clinician, requiring prioritisation and organisational skills.

WHAT ABOUT THE AFTERNOON?

Tutorials based in Imperial Campuses will start at 2pm and run until 5pm every Thursday. These will give you an opportunity to debrief with peers and course leads, present interesting cases (both from Integrated Clinical Apprenticeship and your firms) and receive tutorials based around course themes, relevant to the Year 5 core specialties.

ARE THERE ANY ASSESSMENTS OR WRITE UPs?

There are no formal assessments in the Integrated Clinical Apprenticeship. However, there are some exercises during the year that are designed to help you reflect on your Year 5 learning with regard to your Integrated Clinical Apprenticeship work.

WHAT IF I CAN’T ATTEND A SESSION?

You first priority in this instance is to your patients and your surgery. Please let them know as soon as possible that you cannot attend so that they can inform your booked patients. Please also email the course administrator Noosheen Bashir (n.bashir@imperial.ac.uk). You should always notify us prior to being absent from a session so that our records are accurate.

Research Outputs of England’s Hospital Episode Statistics Database

Hospital administrative data, such as those provided by the Hospital Episode Statistics (HES) database in England, are increasingly being used for research and quality improvement. To date, no study has tried to quantify and examine trends in the use of HES for research purposes. We therefore examined trends in the use of HES data for research. Our study was published in the Journal of Innovation in Health Informatics.

Publications generated from the use of HES data were extracted from PubMed and analysed. Publications from 1996 to 2014 were then examined further in the Science Citation Index (SCI) of the Thompson Scientific Institute for Science Information (Web of Science) for details of research specialty area. 520 studies, categorised into 44 specialty areas, were extracted from PubMed. The review showed an increase in publications over the 18-year period with an average of 27 publications per year, however with the majority of outputs observed in the latter part of the study period. The highest number of publications was in the Health Statistics specialty area.

We concluded that the use of HES data for research is becoming more common. Increase in publications over time shows that researchers are beginning to take advantage of the potential of HES data. Although HES is a valuable database, concerns exist over the accuracy and completeness of the data entered.

DOI: http://dx.doi.org/10.14236/jhi.v24i4.949

Research outputs of primary care databases in the United Kingdom: bibliometric analysis

Data collected in electronic medical records for a patient in primary care in the United Kingdom can span from birth to death and can have enormous benefits in improving health care and public health, and for research. Several systems exist in the United Kingdom to facilitate the use of research data generated from consultations between primary care professionals and their patients. General Practitioners play a gatekeeper role in the UK’s National Health Service (NHS) because they are responsible for providing primary care services and for referring patients to see specialists.

In more recent years, these databases have been supplemented (through data linkage) with additional data from areas such as laboratory investigations, hospital admissions and mortality statistics. Data collected in primary care research databases are now increasingly used for research in many areas, and for providing information on patterns of disease. These databases have clinical and prescription data and can provide information to support pharmacovigilance, including information on demographics, medical symptoms, therapy (medicines, vaccines, devices) and treatment outcomes.

We examined the number of research outputs from three primary care database, CPRD, THIN and QResearch, assessing growth and publication outputs over a 10-year period (2004-2013) in a study published in the Journal of Innovation in Health Informatics. The databases collectively produced 1,296 publications over a ten-year period, with CPRD representing 63.6% (n = 825 papers), THIN 30.4% (n = 394) and QResearch 5.9% (n = 77). Pharmacoepidemiology and General Medicine were the most common specialties featured.

Career opportunities for GPs in North and West London

On Wednesday 22 November 2017, I spoke at an event organised by the North and West London Faculty of the Royal College of General Practitioners. The event was aimed at ‘First Five’ general practitioners. I spoke on the topic of opportunities in research. The event was chaired by Dr Camille Gajria and Dr Nilesh Bharakhada. Other speakers at the conference included Dr Ian Goodman, Chair of Hillingdon CCG, who spoke on the topic of emerging opportunities for GPs through new models of care; Dr Sohail Hussain who spoke on media opportunities; Dr Krishan Aggarwal who spoke on finance; Dr Shivani Tanna who spoke on teaching opportunities; Dr Sonia Tsukagoshi who spoke on international opportunities; and Dr Nilesh Bharakhada who spoke on the Care Information Exchange and opportunities in technology for GPs. The event was a good opportunity for First Five GPs to learn about career opportunities in London and also update themselves on areas such as personal finance and key developments in the NHS in London, such as new care models.

Tobacco control efforts in the Gulf Cooperation Council countries

A paper published in the Eastern Mediterranean Health Journal  reviews the current state of tobacco use, governance and national commitment for control, and current intervention frameworks in place to reduce the use of tobacco among the populations of the Gulf Cooperation Council (GCC) member states and Yemen. It further reviews structured policy-oriented interventions (in line with the MPOWER package of 6 evidence-based tobacco control measures) that represent government actions to strengthen, implement and manage tobacco control programmes and to address the growing epidemic of tobacco use.

The findings of the review show that tobacco control in the GCC countries has witnessed real progress over the past decades. These are still early days but they indicate steps in the right direction. Future investment in implementation and enforcement of the Framework Convention on Tobacco Control, production of robust tobacco control legislation and the establishment of universally available tobacco cessation services are essential to sustain and strengthen tobacco control in the GCC region.