Medical Centre

In some parts of England, proposals are emerging to divide NHS primary care services into separate pathways for acute, same-day care and long-term, complex care. While this approach aims to manage the growing workload in general practice, it raises significant concerns about potential negative impacts on patient care and NHS efficiency. We discuss the implications of these proposals in an article published in the British Medical Journal.

The Holistic Strength of General Practice

One of the key strengths of general practice lies in its holistic approach, where GPs offer continuous and comprehensive care. This continuity allows GPs to maintain a thorough understanding of a patient’s medical history, lifestyle, and psychological aspects, leading to effective and cost-efficient care. Fragmenting services by separating acute and long-term care threatens this holistic approach and can undermine the management of chronic conditions, which often include acute episodes linked to ongoing health issues.

Risks of Fragmentation

Missed Diagnoses: Acute symptoms can sometimes signal more severe underlying conditions. For instance, a chronic cough could indicate serious diseases like lung cancer or tuberculosis. Fragmented services reduce opportunities for comprehensive health evaluations, increasing the risk of missed diagnoses and neglecting critical health promotion activities.

Increased Costs and Confusion: Splitting primary care services could lead to higher healthcare costs due to duplicated services and administrative overheads. Vulnerable groups, such as older adults and non-native English speakers, may find the fragmented system confusing, further hindering their access to appropriate care.

Impact on GP Training: The separation of services could negatively affect the education of GP registrars and ongoing professional development. Exposure to both acute and complex cases is essential for developing well-rounded, competent GPs. Limited supervision in “acute care hubs” may not provide the diverse learning experiences necessary for effective training.

Advocating for Integrated Care

To maintain the effectiveness and efficiency of primary care, it’s essential to focus on integrated care models rather than fragmented services. Integrated care ensures that both acute and long-term health needs are addressed within a cohesive system, leading to better health outcomes and more efficient resource use.

Multidisciplinary Teams: Incorporating multidisciplinary team members such as district nurses, therapists, social workers, pharmacists, care coordinators, and social prescribers can help address a full spectrum of health issues, fostering stronger patient-provider relationships and improving patient satisfaction.

Reducing Administrative Burden: Training non-clinical staff to handle administrative tasks can free up GPs to focus more on patient care. Additionally, improving the integration of health records across primary and secondary care can reduce data entry duplication and enhance record accuracy.

Conclusion

To preserve the essence of primary care and its patient-centred approach, efforts should be directed towards strengthening integrated care models, enhancing general practice capacity, and improving service efficiency. By avoiding the pitfalls of fragmented services, we can ensure that primary care continues to meet the evolving health needs of the population without compromising quality, cost, or continuity of NHS care.

Read Preserving the Essence of NHS Primary Care in full

Our new study in the Journal of Multimorbidity and Comorbidity sheds light on the challenges of assigning disease clusters to people with multiple long-term conditions

In the world of healthcare, understanding how to manage and treat multiple long-term conditions (MLTC) is a significant challenge. our explores the effectiveness of different strategies for assigning disease clusters to people with MLTCs, aiming to improve our understanding of health outcomes.

The study, a cohort analysis using primary care electronic health records from England, involved a massive sample of over 6.2 million patients. It evaluated the performance of seven different strategies for grouping diseases into clusters, with the aim of predicting mortality, emergency department attendances, and hospital admissions.

What are Disease Clusters?

Disease clusters are groups of conditions that frequently occur together, which may represent underlying shared causes or risk factors. By identifying these clusters, researchers hope to tailor preventive and therapeutic strategies more effectively.

Findings from the Study

We found that while assigning patients to disease clusters could provide a structured way to understand MLTCs, none of the strategies were particularly effective at predicting health-related outcomes when compared to considering each disease individually. Specifically, the method that counted the number of conditions within each cluster performed the best among the cluster-based strategies, but still fell short compared to a disease-specific approach.

This highlights a critical limitation: diseases within the same cluster may not consistently relate to health outcomes, suggesting that the clusters, while useful for some research applications, might not be reliable for predicting patient outcomes.

Implications for Healthcare

The study underscores the complexity of treating individuals with MLTCs. It suggests that while clustering diseases can help in understanding some aspects of multimorbidity, relying solely on these clusters to predict health outcomes might oversimplify the nuances of individual patient conditions.

For healthcare providers and policymakers, these findings emphasize the need for personalized treatment plans that consider the unique combination of diseases each patient has, rather than applying broad cluster-based approaches.

Future Directions

The researchers recommend further exploration into how disease clusters can be used in conjunction with individual disease information to improve health outcome predictions and treatment strategies. This might include integrating machine learning techniques that can handle large datasets and complex variable interactions more effectively.

Conclusion

This study provides valuable insights into the challenges and limitations of using disease clusters as a tool for managing MLTCs. It calls for a more nuanced approach that balances the simplicity of clustering with the complexity of individual patient profiles, ensuring that treatment strategies are both scientifically sound and tailored to meet individual needs.

For healthcare systems, continuing to invest in research that refines our understanding of MLTCs will be crucial for developing more effective and personalized approaches to treatment and care management in the future.

Read Assigning disease clusters to people with multiple long-term conditions in full

In the quest to refine healthcare delivery in England, this innovative approach, inspired by Brazil’s successful community healthcare model, is a promising solution to the challenges faced by the NHS. The strategy focuses on the deployment of Community Health and Wellbeing Workers (CHWWs) to foster more efficient, localised healthcare services. Our recent article in the British Journal of General Practice discusses the potential of this model and how it could revolutionise healthcare in communities across England.

The Inspiration from Brazil

Brazil’s community healthcare model stands as a testament to the power of grassroots health initiatives. Over the past two decades, this approach has led to significant improvements in health outcomes, including reductions in cardiovascular mortality, hospital admissions, and health inequalities. The core of Brazil’s success lies in the integration of CHWWs into the healthcare system. These workers serve as pivotal links between GPs, community services, local authorities, and the communities they serve, especially in marginalized areas.

Pilot Program in Westminster

A pilot program in Westminster tested the feasibility of this model in England. The results were promising, showing increased vaccination and screening rates, along with a 7% drop in unscheduled GP visits in the first year alone. This indicates that CHWWs not only meet the existing demand for healthcare services but also successfully reach those in need of care who might not seek it out.

Addressing the Workforce Crisis

Beyond improving healthcare delivery, training and employing CHWWs offer a strategic solution to the current NHS workforce crisis. By upskilling volunteers and providing them with pathways to employment within the NHS, this initiative could significantly alleviate workforce shortages. Moreover, the role of a CHWW, demanding cultural competence, a non-judgmental attitude, and strong problem-solving skills, represents an attractive career opportunity for individuals passionate about community service.

Potential Impact in England

The adaptation of Brazil’s community health worker model to the English context could yield even greater benefits due to the wider availability of services. Acting as catalysts between healthcare, social care, and public health, CHWWs could play a crucial role in improving population health status and outcomes. The initial successes observed in Westminster suggest that a nationwide deployment of CHWWs could lead to considerable savings within public health, social care, and NHS budgets, alongside notable improvements in public health.

Funding and Support

For the CHWW initiative to be sustainable, securing long-term and reliable funding is essential. Proposals suggest adding to the fixed part of the Public Health Grant as a viable funding source. This approach aligns with the broader goal of creating an English family health strategy, which is both a feasible and cost-effective solution to current healthcare challenges.

Conclusion

The introduction of Community Health and Wellbeing Workers in England represents a forward-thinking solution to improving healthcare accessibility and efficiency. Inspired by Brazil’s model, this approach offers a holistic and integrated strategy to address the pressing challenges of the NHS, including strained budgets, workforce shortages, and the need for improved public health outcomes. With appropriate funding, support, and expansion across the country, CHWWs have the potential to significantly enhance the healthcare landscape in England, making it more responsive to the needs of its diverse populations.

Read Community health and wellbeing workers: a solution for improving health and care in England in full

Our study in published in BMJ Medicine in February 2024 examined the effect of defining timeframes for long-term conditions on the prevalence of multimorbidity in England, and on the role played by sociodemographic factors. Using primary care electronic health records from the Clinical Practice Research Datalink Aurum, the study included over 9.7 million adults registered in England as of 1 January 2020, focusing on 212 long-term conditions.

Key Findings

Varying Prevalence Rates: The prevalence of multimorbidity, defined as the coexistence of two or more long-term conditions, varied widely based on the timeframe used for definition. It ranged from 41% with stricter criteria (requiring three codes within any 12-month period) to a 74% when a single diagnostic code was deemed sufficient. Using conditions marked as active problems resulted in the lowest prevalence rate at 35%.

Sociodemographic Influences: The study revealed that younger individuals, certain minority ethnic groups, and those living in areas of lower socioeconomic deprivation were more likely to be reclassified as not multimorbid under timeframes that required more than one diagnostic code. This suggests that these groups are disproportionately affected by the criteria used to define long-term conditions.

Implications for Healthcare Policy and Research: The substantial variation in multimorbidity prevalence underscores the challenges in directly comparing estimates of multimorbidity between studies. It highlights the need for clear rationales behind the choice of timeframe and suggests a potential bias introduced by definitions requiring multiple codes. We recommended that researchers provide their reasoning for the timeframe choice and consider sensitivity analyses to explore the impact on different patient groups.

Addressing Multimorbidity in Healthcare

The findings emphasize the complexity of measuring multimorbidity and the influence of methodological decisions on prevalence estimates. This has important implications for healthcare policy, practice, and research; stressing the importance of adopting a nuanced approach to understanding and addressing the needs of people with multiple health conditions. It calls for a balance between the granularity of condition definitions and the practicality of healthcare delivery, ensuring that healthcare systems can adequately respond to the nuanced needs of its diverse patient population.

Conclusions

The study serves as a critical reminder of the dynamic nature of health conditions and the need for healthcare systems to adapt their approaches to effectively manage multimorbidity. It opens avenues for further research into optimising care for individuals with multiple long-term conditions, ultimately aiming to enhance clinical outcomes, patient experience quality of life, and healthcare efficiency.

Read Exploring the Impact of Diagnostic Timeframes on Multimorbidity Prevalence in England in full

Pharmacies in England to begin treating patients for seven common conditions. How can we work successfully across the health and care system to make a success of Pharmacy First?

1. The Pharmacy First scheme aims to provide convenient access to healthcare through community pharmacies. Patients with minor ailments or common conditions can seek advice and treatment directly from their local pharmacy instead of visiting a general practice, urgent care centre or emergency department. The conditions covered by the scheme may vary depending on local funding arrangements and participation of pharmacies.

2, A potential problem with Pharmacy First is pharmacists misdiagnosing a patient’s condition. It may also lead to delays in patients seeing doctors when medical assessment is needed. To mitigate these risks, appropriate safeguards and referral pathways should be established, ensuring timely medical assessment when necessary. The scheme will also increase the workload of pharmacies, thereby reducing the time available for other areas of work.

3. To ensure the successful implementation of Pharmacy First, it is essential to develop strong partnerships between key partners in the scheme such as pharmacies, general practices, and integrated care boards. Good communication to share information, updates about the scheme and best practice among all organisations involved is also needed; as is ensuring clear roles and responsibilities for all partners in the scheme.

4. The use of guidelines and protocols that outline the specific tasks, workflows, and processes involved in the scheme will ensure that all partners are aware of their responsibilities. This will keep partners well-informed about their responsibilities and help maintain consistent standards. Comprehensive training and educational resources for community pharmacists and other pharmacy staff are also needed, including continuous professional development and regular audits of clinical practice.

5. The NHS needs to integrate IT systems between pharmacies and general practices to facilitate efficient and accurate transfer of patient information, and to ensure good continuity of care. Additionally, the use of digital technologies and telehealth solutions should be explored to enhance follow-up and patient monitoring when required.

5. As Pharmacy First is relatively new, robust performance monitoring and evaluation are needed to assess its costs, clinical effectiveness, effects on other parts of the NHS and impact on patient satisfaction. This requires the development of key performance indicators to measure the scheme’s outcomes in these areas, enabling evidence-based decision-making and continuous quality improvement.

6. Improving public awareness and engagement is crucial. Implementing media campaigns to inform the public about the scheme’s availability and benefits will help drive its adoption. Furthermore, proactive engagement with patients, community groups, and other stakeholders, particularly those from underserved groups, will ensure inclusivity and provide valuable feedback for ongoing improvement of the scheme.

References

1. Clinical pharmacists in primary care: a safe solution to the workforce crisis? https://journals.sagepub.com/doi/full/10.1177/0141076818756618

2. Impact of integrating pharmacists into primary care teams on health systems indicators: a systematic review. https://bjgp.org/content/69/687/e665.full

Read How can we make a success of Pharmacy First? in full

The objective for the NHS in England to provide high-quality, personalised care for all patients is a vision that requires a transformative approach to healthcare delivery. This shift signifies a move from the primarily finance and target-driven models of healthcare delivery that we have now to ones that are more patient-centred, emphasising the importance of individual patient needs and outcomes as well as the well-being of NHS staff.

In the international context, healthcare systems around the world are grappling with similar challenges: how to deliver care that is both high-quality and cost-effective, while also addressing the needs of an aging population and the rise of chronic diseases. Many countries are looking towards patient-centred care as a solution.

The World Health Organization (WHO) has also advocated for patient-centred care as part of its strategy to strengthen healthcare systems globally. It emphasizes that patient-centred approaches can lead to better health outcomes, more cost-effective services, and higher patient and staff satisfaction.

However, health systems globally faces unique challenges in implementing such care. For the NHS to adopt a patient-centred model successfully, it can draw on the lessons learned from these international experiences, adapting best practices to fit the unique context of the UK healthcare system. The global shift towards patient-centred care is not a fleeting trend but a response to the clear evidence that such approaches work. By adopting and adapting these international best practices, the NHS can continue to be a leader in healthcare delivery, providing care that is not only effective and efficient but also equitable and respectful of patients’ needs and values.

A more holistic approach to health care delivery would involve:

1. Patient-Centred Care: Tailoring treatment plans to the individual needs and preferences of patients, and ensuring that they are active participants in their own care. This would also involve respecting patient autonomy and decision-making.

2. Staff Well-being: Recognizing that the health and well-being of NHS staff are crucial to patient care. This would involve providing support systems, adequate staffing levels, and addressing burnout and job stress.

3. Quality Over Quantity: Instead of focusing just on meeting quotas and targets, the emphasis should be on the quality of care provided. This could mean more time for patient consultations, and follow-ups, and ensuring that treatments and interventions are evidence-based and help improve health outcomes for patients.

4. Integrated Care: Ensuring continuity of care across different services and providers, which require effective communication and collaboration among primary care, hospitals, mental health, community services, and social care.

5. Preventive Care: Shifting the focus of the NHS towards prevention and early intervention, which can improve long-term health outcomes and reduce the need for more intensive and expensive treatments later.

6. Accessibility and Inclusivity: Making healthcare services accessible to all sections of the population, particularly marginalised groups, thereby addressing health inequalities, and ensuring that healthcare is more equitable.

7. Investment in Staff Training: To deliver personalised care, there is a need for continuous professional development and training for NHS staff, equipping them with the skills to adapt to a more holistic and patient-focused approach.

8. Feedback and Improvement: Regularly collecting and acting on feedback from both patients and staff to improve services and care quality.

9. Technology and Innovation: Leveraging technology to improve patient care, such as through telemedicine, while also ensuring that it does not replace the human touch which is essential in providing compassionate care.

10. Mental Health Focus: Recognizing the mental health component as integral to overall health, ensuring that mental health services are as accessible and well-funded as physical health services.

To achieve this vision requires not only structural and policy changes within the NHS but also a cultural shift that values and prioritises the holistic well-being of patients and healthcare workers alike. This transformation can lead to a more sustainable health service that is better equipped to meet the current and future health needs of the population; such as addressing the health needs of older people and those with complex multimorbidity.

The path to a more patient-centred NHS is both a necessary and achievable evolution in healthcare delivery in England. By embracing a model that places the patient at the heart of care, values the well-being of healthcare staff, and integrates innovation with compassionate services, the NHS can not only enhance the health of individuals but also the health of our society.

This shift, grounded in the principles of accessibility, prevention, and personalised treatment, can forge a stronger, more resilient healthcare system that is equipped to meet the diverse and complex needs of the population in the 21st century. The future of the NHS, therefore, lies not only in numbers and targets, but in the quality of care and the health outcomes of its patients and the national population, marking a return to the core values that have long been the foundation of the NHS.

Read How can the NHS provide personalised care to patients? in full

In a letter published in the British Medical Journal, I discuss why the UK government must be more proactive about drug addressing shortages in the NHS.

The lack of drugs such as methylphenidate required for the treatment of attention deficit/hyperactivity disorder (ADHD) is the latest of many medication shortages we have seen in the UK in recent years.1 These shortages are now too frequent and waste the time of NHS staff such as general practitioners and pharmacists who have to spend time counselling patients and sourcing alternative drugs instead of focusing on more relevant work. They are also very stressful for patients who risk going without key drugs with potentially adverse consequences for their health. For people with ADHD, for example, this could mean going without medication that they require to function effectively at work and school and in their personal relationships.

We need a much more proactive approach from the government, which needs to work with drugs manufacturers and wholesalers to ensure that the NHS has adequate supplies of key drugs to prevent such problems occurring in the future. This could include better data on drug supply and demand to identify problems before they occur; improving local manufacturing capacity in the UK for essential drugs needed by the NHS; price incentives for suppliers; and international collaboration to ensure continuity of drug supply. Moreover, immediate support mechanisms should be put in place for primary care teams grappling with the increased workload caused by these shortages. Patients too could benefit from help such as national helplines or online support to allow them to cope better with the consequences of drug shortages.

Until we see active intervention by government, working in partnership with the NHS and industry, patients in the UK will continue to be affected and the time of NHS staff will continue to be wasted because of drug shortages.

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