Tag: Primary Care

Why I don’t support GPs taking industrial action

I don’t support the BMA’s view that NHS GPs in England should consider taking industrial action. I think this will alienate the public and lose GPs support at a critical time. NHS England is not going to invest adequately in the current independent contractor model of general practice. Why does the BMA not ballot GPs about the NHS salaried option instead whereby GPs and their staff would become NHS employees?

The BMA’s GP Committee has always opposed the option of GPs becoming salaried employees of the NHS. For many years, NHS England has been unwilling to fully support the independent contractor model of NHS general practice. Instead, we are going to find the independent model gradually fading and GPs increasingly being employed by commercial companies contracted to deliver NHS services.

This will be a much worse outcome for GPs and patients than other alternatives. And in anticipation of all the responses from GPs about why the current independent model is better than salaried NHS employment, I know these arguments well and list them in a blog I published in 2013. I have been a GP partner for over 20 years and know how this model of NHS primary care works, including its strengths and weaknesses.

I make the counter argument about why we should pursue the option of GPs becoming salaried employees of the NHS (like the > 1m current NHS employees in the UK ) in an article I published in the BMJ in 2016. The BMA needs to consider this employment model seriously if it is to make working as a primary care doctor viable.

All the BMA’s attempts to prop up the independent contractor model of general practice in their negotiations and discussions with NHS England over the last 10 years have failed. Their latest attempt will also fail.

Patient-initiated second medical opinions in healthcare

A second medical opinion is a medical decision-making tool for patients, physicians, hospitals and insurers. For patients, it is a way to gain an additional opinion on a diagnosis, treatment or prognosis from another physician. Physicians seeking another colleague’s opinion may refer a patient to another consultant to gain further advice. Many health insurers mandate second opinion programmes to reduce medical costs and eliminate ineffective or suboptimal treatments. Hospitals may also require second reviews as part of routine pathology, radiology reviews or for legal purposes. consultant to consultant referrals. Patients in primary care may also request an opinion from a second specialist when unhappy with the opinion from the first specialist.

We carried out a systematic review to summarise evidence on (1) the characteristics and motivating factors of patients who initiate second opinions; (2) the impact of patient-initiated second opinions on diagnosis, treatment, prognosis and patient satisfaction; and (3) their cost effectiveness. The reivew was published in BMJ Opinion.

Thirty-three articles were included in the review. 29 studies considered patient characteristics, 19 patient motivating factors, 10 patient satisfaction and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle-age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reported on the cost effectiveness of patient initiated second opinions.

The review identified several demographic factors associated with seeking a second opinion, including age, gender, health status, and socioeconomic status. Differences in opinion received, and in the impact of change in opinion, varies significantly between medical specialties. More research is needed to understand the cost effectiveness of second opinions and identify patient groups most likely to benefit from second opinions.

DOI: http://dx.doi.org/10.1136/bmjopen-2020-044033

Will the NHS survive without GPs?

That rhetorical questions like the recent one posed by some in the media are even asked shows how deeply ill-informed and distorted the discourse on healthcare has become in the UK. Any dispassionate observer would know that GPs are the bedrock of the NHS; and without GPs the NHS will collapse. Here are just a few home truths: GPs in England manage a wide array of acute and chronic health conditions through over 300 million patient consultations each year compared to 23 million A&E visits. [1] GPs issue about one billion prescriptions annually and have delivered two thirds of phase 1 covid-19 vaccinations. [2]

The public already know how hard their family doctors are working to care for them. Despite the challenges of the pandemic, soaring demand, a shrinking GP workforce and a workload that has often become unmanageable, GPs have one of the highest public satisfaction ratings of any public service in the UK. In a survey in July 2021, an overwhelming majority of patients (83%) rated their overall experience of GPs as good and 48.2% rated their experience as “very good.” [3] By contrast, in a comparable UK survey of adult hospital inpatients for overall experience in 2019, 48% of patients gave a score of 9 or 10 (good or very good).

General Practitioners are highly skilled professionals who manage extremely complex medical conditions with limited access to resources, including high-tech diagnostics, available in secondary care. GPs not only treat medical conditions, but through their longitudinal and relationship-based care, also manage non-medical problems. One in five patients consults general practitioners for primarily social problems rather than medical. [4]

Much of the reputation of the NHS in international league tables (ranked number one health system out of 11 countries in 2017 and fourth in 2021) rests on the efficiency and excellence of its primary care. [5,6] A year’s worth of GP care per patient costs less than an A&E visit and less is spent on general practice than on hospital outpatients. GP practices were paid an average £155 per patient in 2019/2020, but the average cost of treatment in A&E, without the cost of ambulance or overnight admission, could be up to £400. Yet for the past two decades funding for hospitals has grown twice as fast as for general practice. [1] Further, between 2005/6 to 2017 the proportion of money spent in general practice fell from 9.6% to 8.1%.

Recent surveys show two in three patients (67%) are satisfied with the appointment times available to them and 67% find it easy to get through to GPs. [3] General practice had to quickly adapt during the pandemic to provide safe care by fulfilling their public health role in protecting their patients and the community from covid-19. More patients now consult in primary care than the pre-pandemic with over half these appointments face to face. [7] There are however serious problems and challenges that patients face including access to GP services and the quality of their care.

The public deserves honesty and courage from political leaders, commentators, and policymakers. Rather than skirting over facts by blaming GPs, who currently deliver over 31 million appointments per month in England, politicians need to be honest with the public on what kind of healthcare the population needs and what they are currently getting.

The UK spends less per capita on healthcare than other comparable countries (0.27% of GPD compared to an OECD average of 0.51%). [8] The UK also has one of the lowest numbers of doctors in leading European countries relative to its population, behind Estonia, Slovenia, and Latvia (about 2.9 per 1,000 people, compared with an average of 3.5 doctors across the OECD). The OECD figure also includes hospital doctors which have grown. In England, between 2004 and 2021 the number of hospital consultants has risen by 83% (from 28,141 to 51,490). On the other hand, the number of permanent and locum qualified GPs in England has fallen with fewer GPs in December 2020 than the year before. The Nuffield Trust analysis shows the number of GPs relative to the size of the population has fallen in a sustained way for the first time since the 1960s with the shortage particularly marked in some English regions.

Lack of an adequate GP workforce is only part of the problem. The recent media attacks on GPs highlights a total disregard for a workforce already at breaking point. A record number of GPs are seeking mental health counselling, and many are leaving the workforce by taking early retirement or working abroad. Therefore, the question that we must ask is: if the NHS collapses, who will notice it? Those with platforms to undermine the NHS will be unlikely to notice it. The elite has the means and resources to seek healthcare outside the NHS and even abroad, but for everyone else the collapse of the system will be catastrophic.

The solution starts with putting a stop to attacks on GPs and the NHS by politicians and the permanently outraged sections of the media. Secondly, to achieve health outcomes comparable to other OECD countries, the NHS must tackle workforce shortages and the decline in quality of services. [9] The increasing health needs of an ageing population and the growing demand for better healthcare require more than alienating and undermining a workforce on whom the NHS depends. General practice could make better use of non-medical professionals such as social prescribers to reduce the workload and people could be sign-posted to services in the community without a GP referral. The administrative burden on primary care is also unsustainable and must be reduced; for example, by suspending CQC inspections. We also need a dialogue between the public, professionals, and politicians about what kind of primary care system they want in the UK; with plans then backed up with the appropriate level of investment. Health systems with a strong primary care infrastructure can achieve better health outcomes, improve patient experience, and reduce pressures elsewhere in the NHS. This should be the objective that we strive to achieve.

Mohammad Sharif Razai, NIHR In-Practice Fellow in Primary Care, St George’s University of London. Twitter: @mohammadrazai

Azeem Majeed, Professor of Primary Care & Public Health, Department of Primary Care & Public Health, Imperial College London @Azeem_Majeed

This article was first published in BMJ Opinion.

References:

  1. NHS England. Primary Care. Available from: https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/primary-care/ (accessed 19 September 2021)
  2. Patient Information. Where to get medication in an emergency. Available from: https://patient.info/news-and-features/where-to-get-medication-in-an-emergency (accessed 19 September 2021)
  3. NHS England.  GP Patient Survey 2021. Available from: https://www.england.nhs.uk/statistics/2021/07/08/gp-patient-survey-2021/ (accessed 19 September 2021)
  4. Advice Services Alliance. The role of advice services in health outcomes: evidence review and mapping study. 2015. https://www.thelegaleducationfoundation.org/wp-content/uploads/2015/06/Role-of-Advice-Services-in-Health-Outcomes.pdf.
  5. The Commonwealth Fund. Mirror, Mirro 2017. Available from: https://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/ (accessed 19 September 2021)
  6. The Commonwealth Fund. Mirror, Mirror 2021. Available from: https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly (accessed 19 September 2021)
  7. Royal College of General Practitioners. College sets record straight on face-to-face GP appointments. August 2021. Available from: https://www.rcgp.org.uk/about-us/news/2021/august/college-sets-record-straight-on-face-to-face-gp-appointments.aspx (accessed 19 September 2021)
  8. The Health Foundation. The UK spends less on capital in health care than other comparable countries. 2019. Available from: https://www.health.org.uk/news-and-comment/charts-and-infographics/the-uk-spends-less-on-capital-in-health-care-than-other-comp (accessed 19 September 2021)
  9. Papanicolas I, Mossialos E, Gundersen A, Woskie L, Jha A K. Performance of UK National Health Service compared with other high income countries: observational study  BMJ  2019;  367 :l6326 doi:10.1136/bmj.l6326

Why MPs and journalists need to speak to their local general practices

The UK’s MPs and journalists repeatedly say they want “GPs to get back to work”. But instead of asking this, they need to speak to staff in their local general practices to understand what the issues are that are causing problems for patients in gaining access primary care services, whether via a face to face appointment or by telephone. The number of GPs per person in England has declined in recent years. At the same time, the volume and complexity of care has increased steadily year-on-year. These problems have been compounded by the rebound in primary care activity following an initial fall at the start of the Covid-19 pandemic. Many GPs report that they and their teams are now dealing with a record level of work.

In this context, asking GPs to “get back to work” is insulting for them and their teams. GPs made major changes in the way they work at the start of the Covid-19 pandemic to protect patients – with little additional support from NHS England – and are now struggling with long-term shortages of doctors and other staff, and unsafe levels of workload. If GPs and journalists spoke to the staff in their local general practices, they would understand these issues better and also be more aware of potential solutions. Better-informed MPs and journalists might then actually be able to apply pressure on the government to urgently address the many problems that face NHS general practices in England, and bring an end to the culture of “sticking plaster solutions” that NHS England has offered in recent years.

GPs should not be made scapegoats for political failings

A recent article in the Daily Telegraph article asked “If the GPs went on strike, would anybody notice?” The article claimed that no one would notice if GPs went on strike and the author suggested that making all GPs salaried, forcing them to work longer hours, would help improve general practice for patients. The author quoted “a now retired GP in his 90s from Bristol who continued doing locum work until five years ago,” who apparently said, “Many GPs are using covid-19 as an excuse for not providing good clinical services. Being able to opt out of night/weekend cover and only working two or three days a week have caused the demise of general practice to the detriment of patients.”

As GPs we have worked throughout this pandemic often face-to-face in the most basic of personal protective equipment (PPE), and we were disheartened to read this piece.

GPs and their teams have played an essential role throughout the pandemic. GP teams in England alone deal with over 300 million contacts each year. General Practices have been running community hot covid clinics, and supporting NHS 111 and the Covid Clinical Assessment Service (CCAS). We are supporting 5.5 million patients on NHS waiting lists, who are often in severe pain and in need of extra support, as well as supporting about 1 million patients with the effects of long covid, and adapting to new ways of working enforced by a global pandemic. In addition, our teams have delivered the majority of covid vaccinations thus far. We are currently being asked to recall our most clinically vulnerable patients for their third covid booster vaccination. All this has been achieved despite the proportion of the NHS budget spent on NHS general practice and the number of GPs per person both declining in England in recent years.

We are already seeing that any small reduction in GP access causes rapid spill over into Emergency Departments, so just imagine if there were no GP service at all. The NHS would collapse. When GPs began to pull back from the covid-19 vaccination programme because of the mass vaccine sites taking over, for example, the rate of vaccination slowed—especially in the hardest to reach groups—and complaints increased from patients unable to access vaccine appointments.

If we look at prescriptions, GPs and their teams issue a vast number every year. If another part of the NHS tried to take on this work, an army of people would be needed—doctors, pharmacists, and administrative staff. Many higher risk medications need careful monitoring and regular review. Patients on most regular medication also require medication reviews, checks (e.g., blood tests, measuring blood pressure) to monitor safe prescribing and prevent drug interactions, and to deal with queries and frequent shortages and changes of medicines. The efficient systems that GPs have developed for prescribing means that they issue many prescriptions that would be given by hospital specialists in other countries.

Moreover, every patient seen in secondary care generates a letter, often with requests for GP teams to follow up patients, monitor their treatment, arrange blood tests, or prescribe.

The work of a GP can be incredibly rewarding as we build long term relationships with people over years, and there is strong evidence for the benefits of continuity of care (for both patients and the care provider).  GPs are true “generalists” and the uncertainty of undifferentiated illness is stressful, especially when working remotely. GPs in the UK work at a higher level of intensity than elsewhere in Europe. GPs in the UK have the shortest consultation times in Europe, and UK GPs tend to see more than twice the safe recommended number of patients per day.

BMA appointment data show huge increases in activity over the past 18 months. Yes, there are more telephone appointments and fewer face to face appointments, but this is the same in all sectors of society—and the same for both community and hospital care. It should come as no surprise, or make headline news, because remote working is in line with direct government policy and is there to protect both patients and staff from a highly infectious and potentially lethal virus. It is especially important to protect the many vulnerable individuals we look after in general practice, in a time when there are over 30,000 covid-19 cases reported daily in the UK.

Despite political promises for an additional 6000 additional GPs in England by 2024, there has been a reduction in numbers rather than an increase. While there is a clear link between ratios of family doctors and life expectancy, the number of patients per practice is now 22% higher than it was in 2015, and the GP workforce has not grown with this demand. As a result, there are now just 0.46 fully qualified GPs per 1000 patients in England, down from 0.52 in 2015, which, when added to growing demand from the rising number of people living with complex chronic illness and poverty along with an ageing population, means that primary care is in a desperate situation. GP turnover is higher in deprived areas further exacerbating health inequalities.

Demand on general practice is increasing, while at the same time general practices are struggling to recruit staff. The current deepening GP crisis that we are facing is having widespread effects on patient care nationwide. The current crisis long predated covid-19, but the pandemic has highlighted the large cracks in the NHS. GP teams should not be made scapegoats for the political failings, under-funding, and shortages of essential staff, which are the root cause of the issue.

General practice is often described as the “Bedrock of the NHS,” and the NHS Five Year NHS View states that “if General Practice Fails the NHS Fails.” We must be mindful of that, and instead of blaming GPs for the current crisis, look at what can be urgently done to alleviate the crisis.

Simon Hodes, GP partner in Watford, GP trainer, appraiser and LMC rep. Twitter: @DrSimonHodes

Frances Mair, Norie Miller professor of general practice. Twitter: @FrancesMair

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK, Twitter @Azeem_Majeed

This article was first published in BMJ Opinion.

Association between attainment of primary care quality indicators and diabetic retinopathy

Nearly three million people in England have type 2 diabetes. Diabetic retinopathy is a common complication, affecting nearly a third of patients with type 2 diabetes with considerable impacts on visual acuity and quality of life. In a paper published in the journal BMC Medicine, we examined the associations between attainment of primary care indicators and incident diabetic retinopathy among people with type 2 diabetes in England.

We found that that attainment of primary care HbA1c and BP indicators is associated with lower incidence of diabetic retinopathy in patients with type 2 diabetes. There is scope to enhance coverage of HbA1c and BP indicator attainment, and thus to potentially limit the incidence of diabetic retinopathy in England, through appropriate community-based measures. Further research is required to examine whether tighter glycaemic and/or BP control could achieve greater reductions in diabetic retinopathy.

Effectiveness of mental health workers colocated within primary care

Mental health disorders contribute significantly to the global burden of disease and lead to extensive strain on health systems. The integration of mental health workers into primary care has been proposed as one possible solution, but evidence of clinical and cost effectiveness of this approach is unclear. In a paper published in the journal BMJ Open, we reviewed the clinical and cost effectiveness of mental health workers colocated within primary care practices.

Fifteen studies from four countries were included. Mental health worker integration was associated with mental health benefits to varied populations, including minority groups and those with comorbid chronic diseases. The interventions were correlated with high patient satisfaction and increases in specialist mental health referrals among minority populations. However, there was insufficient evidence to suggest clinical outcomes were significantly different from usual general practitioner care.

We concluded that while there appear to be some benefits associated with mental health worker integration in primary care practices, we found insufficient evidence to conclude that an onsite primary care mental health worker is significantly more clinically or cost effective when compared with usual general practitioner care. There should therefore be an increased emphasis on generating new evidence from clinical trials to better understand the benefits and effectiveness of mental health workers colocated within primary care practices.

DOI: http://dx.doi.org/10.1136/bmjopen-2020-042052

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

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

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

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

DOI: https://doi.org/10.2196/23482

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

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

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

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

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

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

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