Medical Centre

A new campaign from NHS England and the UKHSA aims to raise awareness about the prevalence and risks of urinary tract infections (UTIs), particularly among older people and carers, and to reduce hospital admissions related to UTIs.

The campaign offers advice on preventive measures. It emphasizes the importance of staying hydrated, going to the toilet as soon as the need arises, and maintaining hygiene in the genital area. Resources, including posters, are being made available to healthcare services, charities, royal colleges, and care homes to disseminate this information as widely as possible.

The guidance comes ahead of a potentially busy winter season for the NHS, a time when the health service is usually under increased pressure. As part of a larger effort to manage healthcare resources, the campaign encourages the use of alternative services like NHS 111, community pharmacists, and urgent care walk-in centres for less critical cases. This is in line with the broader NHS plan of expanding out-of-hospital care options, including “hospital at home” services and urgent community response teams.

UTIs are particularly dangerous for older adults. Prompt action and early treatment are stressed as critical for managing UTIs and preventing severe outcomes like sepsis or death.

The campaign is part of a larger effort to prepare for increased demand during the winter months and aims to improve public awareness and self-care measures to reduce the need for hospital admissions.

What issues do NHS clinicians need to consider in using this guidance?

1. It is more difficult to diagnose UTIs in older people. Younger people (who will nearly all be women) will usually present with the “classical” symptoms of  UTI – such as frequency, dysuria, urgency and haematuria. Older people can have these symptoms but they can also present with problems such as confusion, agitation, functional decline or lethargy where there is a large overlap with other conditions; making diagnosis more challenging.

2. Another challenge in older people is that some will have asymptomatic bacteriuria (i.e. bacteria in the urine that are not causing problems). When the bacteria are detected, doctors will often treat the patient with antibiotics when the medication may not be needed.

3. Spotting infections early requires knowledge of the symptoms and signs and how these differ in younger and older people. There is also a need to be aware of the complications of UTIs such as sepsis or pyelonephritis and to treat these early.

4. Doctors and patients need to balance the benefits of early diagnosis treatment with the risks of overtreatment with antibiotics. Not all UTIs need antibiotic treatment and some may resolve without it. Overuse of antibiotics contributes to antibiotic resistance as well as putting patients at risk of side effects.

5. Finally, these kind of single issue campaigns will be of limited value unless there is adequate capacity in the NHS for patients to be assessed promptly. Otherwise, patients will end up waiting a long time for appointments with the risk their condition may worsen while waiting for treatment.

Read New Awareness Campaign to Help Reduce Hospital Admissions for Urinary Tract Infections in full

Our new study published in the British Journal of General Practice examines uptake of the NHS App in England. The NHS App was launched in January 2019 as a “front door” to digitally enabled health services, allowing patients to access their personal health information online. With the advent of the COVID-19 pandemic, the app saw a significant increase in downloads, especially with the introduction of the COVID Pass feature. However, the uptake of the app has revealed some important trends and inequalities that need to be addressed.

The Study

A comprehensive observational study used monthly NHS App user data at general-practice level in England from January 2019 to May 2021. Different statistical models were applied to assess changes in the level and trend of use of various functionalities of the app, particularly before and after the first COVID-19 lockdown.

Key Findings

Between January 2019 and May 2021, the NHS App was downloaded 8,524,882 times and registered 4,449,869 users. Intriguingly, the app experienced a 4-fold increase in downloads after the introduction of the COVID Pass feature, which allows users to prove their COVID-19 vaccination status. However, the data also revealed disparities in app registration based on sociodemographic factors:

• There were 25% fewer registrations in the most deprived practices.
• Largest-sized practices had 44% more registrations.
• Registration rates were 36% higher in practices with the highest proportion of registered White patients.
• Practices with a larger proportion of 15–34-year-olds saw 23% more registrations.
• Surprisingly, practices with the highest proportion of people with long-term care needs saw 2% fewer registrations.

What This Means

The findings indicate that while the NHS App has proven to be an useful tool, especially in the times of the Covid-19 pandemic, its usage is not uniform across various sociodemographic groups. This raises questions about accessibility and the digital divide, which could ultimately impact the quality of patient care and health outcomes.

Further Steps

While the app has clearly benefited a significant number of people, it’s crucial to understand the reasons behind these patterns of inequalities. Further research is essential to delve deeper into these trends and how they may affect the patient experience.

Understanding these dynamics can guide improvements to the app, making it more inclusive and effective for all users. Policymakers, developers, and healthcare providers need to work together to ensure that digital health services like the NHS App are accessible and beneficial to everyone, regardless of their socio-economic status or demographic background.

Conclusion

The NHS App has seen a considerable increase in usage since the onset of the Covid-19 pandemic, highlighting its essential role in modern healthcare. However, the unequal patterns in its uptake call for a focused approach to ensure it serves as an inclusive platform for all. Further research is crucial to uncover the underlying reasons for these disparities and to work towards a more equitable healthcare system.

Read Evaluating the Uptake of the NHS App in England in full

Doctors and other NHS professionals in England are often asked to write in support of patients applying for benefits such as Personal Independence Payments (PIP) or Employment Support Allowance (ESA); which support people with disabilities and long-term health conditions.

These benefits are vital for people suffering from long-term health conditions and disabilities, offering them financial help that can significantly improve their wellbeing and quality of life. Given the critical nature of these benefits and the stringent criteria often applied during the assessment process, the letters we write can play an essential role in securing this much-needed support for our patients.

Here is some guidance on how to write a more effective and relevant letter of support based on my long experience as an NHS doctor in writing such letters.

1. Introduce yourself and describe your relationship to the patient, including how long you have known them and in what capacity. This will help establish your credibility as a reliable source of information in support of their application for a personal independence payment or another state benefit.

2. Provide a detailed description of the patient’s medical conditions, including any diagnoses they have received, how their medical conditions affect their daily life, and any symptoms they experience. Focus on the most relevant conditions to their application first. For example, if the patient is applying for PIP due to mobility problems, you should focus on their mobility impairments and how they affect their daily life and ability to work. Also include any medication they are taking and any past medical or surgical interventions.

3. If the patient is applying for Employment & Support Allowance (ESA), explain how their medical condition affects their ability to work. Describe any physical or cognitive limitations they have, or how their symptoms interfere with their ability to perform tasks required for their job. Aim to give precise descriptions of their conditions; for example if they have heart failure, what is the severity?

4. When describing how the patient’s condition impacts their daily life, focus on the activities of daily living that they have difficulty with. For example, you could mention if they have difficulty dressing, bathing, cooking, shopping, cleaning, or managing their finances. Also describe any problems the patients has in managing their health and their medical conditions.

5. Use specific examples to illustrate how the patient’s condition affects their daily life and ability to work. For example, you might describe a time when the patient experienced a symptom flare-up that prevented them from completing a task at home or attending work.

6. Emphasize the patient’s need for financial support through benefits such as PIP or ESA. Explain how this support would help them manage their condition and improve their quality of life. With the cost of living crisis, these benefits are now essential for many people.

7. Remember to keep the letter factual, polite, concise and to the point, and to focus on the patient’s medical conditions (both physical and mental health problems) and how they impact their ability to work and carry out essential daily activities.

Some doctors argue they should not be writing such letters as they detract from the time available from providing core medical services. But obtaining support from a PIP or ESA can improve a patient’s well-being, which ultimately is also beneficial for the NHS and society.

In England, the NHS is funding social prescribers to work with general practices and writing such letters of support is often delegated to these social prescribers who can take over this task from health professionals such as general practitioners and therapists.

Financial problems will have a big impact on people’ health and well-being and it is important that NHS staff do their best to support patients who have difficult financial circumstances because of their health problems.

Read Guidance for NHS staff on writing support letters for patients for applications for PIP or ESA. in full

The importance of the global emphasis on physical activity for health cannot be understated. However, it is crucial to address one of the adverse effects of contact sports—specifically, sport-related concussions. Sport-Related Concussion is a traumatic brain injury caused by a direct blow to the head, neck, or body resulting in an impulsive force being transmitted to the brain.

Sport-Related Concussion can present with a wide range of signs and symptoms, and can affect a person’s thinking, concentration, memory, mood, and behaviour. These incidents are common and account for a significant number of emergency department visits. They also have some long-term risks, including cognitive and neurological problems.

Recent publications, like the consensus statement from the Concussion In Sport Group and the UK Government’s landmark concussion guidance, offer valuable insights in the management of Sport-Related Concussion. This blog – based on our recent article in the British Journal of General Practice – aims to provide guidance on recognising, diagnosing, and managing Sport-Related Concussion within the context of primary care.

 The Changing Landscape of Sport-Related Concussion

In 2016, over 1% of emergency department visits in England and Wales were attributed to concussions. Up to 60% of these involved children and adolescents. A 2021 UK House of Commons report criticised the current awareness level about Sport-Related Concussion in the UK’s NHS, indicating a need for better recording and treatment procedures.

 Recognising Sport-Related Concussion

Symptoms of Sport-Related Concussion can range from cognitive issues to mood changes. Anyone with a suspected concussion should be immediately removed from the field of play and assessed by an appropriate healthcare professional within 24 hours of the injury. Those working in sport will be aware of specialist assessment tools pertaining to individual sports that aid clinicians when diagnosing concussion. The UK Government guidance provides a list of ‘red flags’ that require immediate assessment.

Once Sport-Related Concussion has been recognised or diagnosed, a short period (24–48 hours) of relative rest is advised, where only light-intensity physical activity that does not, or only minimally, exacerbates symptoms is undertaken. Subsequently, a logical graduated return to school/work and then sport can be started, where progression through stages is dependent on minimal and transient (the CSIG advise <1 hour) exacerbation of symptoms.

Sport-specific assessment tools exist for diagnosing concussion, such as the Sport Concussion Assessment Tool (SCAT6). These tools are most effective within 72 hours of the injury and evaluate symptoms, cognitive function, and coordination.

 Managing Sport-Related Concussion in Primary Care

Primary care doctors play an essential role in managing Sport-Related Concussion. Initial management includes:

– Advising a short period of relative rest (24-48 hours)

– Reducing screen time and cognitive load

– No alcohol, solitary time, or driving within the first 24 hours

Patients with persistent symptoms beyond 28 days should be referred for a more comprehensive assessment. Gradual return to normal activities is advised, strictly adhering to symptom-dependent progress.

Challenges and Future Directions

The NHS’s limited specialist services for treating complex or prolonged sport-related concussion symptoms create a care gap. This could be bridged by experts in sports medicine or primary care doctors with extended roles in sports medicine. Emerging technologies like Inertial Measurement Units (IMUs) in mouthguards and salivary micro-RNA samples show promise for better recognition and understanding of sport-related concussion.

Conclusions

Sport-Related Concussion is important. Effective recognition and management by general practitioners can significantly contribute to an individual’s immediate and long-term health. It is also vital for local commissioners to implement appropriate care pathways for managing this condition. By acknowledging the complexities in management and investing in ongoing research, we can create a healthcare system that supports both the benefits of physical activity and the challenges it can sometimes bring.

Read Understanding and Managing Sport-Related Concussion in Primary Care in full

Electronic healthcare records (EHRs) are increasingly being used to collect and store data on patient care. This data can be used for a variety of purposes, such as improving clinical care, conducting research, and monitoring population health. However, it is important to be aware of potential biases in EHR data, as these can lead to inaccurate or misleading results..

The reliability of diagnostic codes in primary care EHRs is a subject of ongoing debate and a topic we investigated in paper published in BMJ Open.

These codes not only guide clinical decisions but also shape healthcare policies, research, and even financial incentives in the healthcare system. A recent retrospective cohort study explored whether the frequency of these codes for long-term conditions (LTCs) is influenced by various factors such as financial incentives, general practices, patient sociodemographic data, and the calendar year of diagnosis. The study comes at a crucial time, shedding light on significant biases that need to be addressed.

Key Findings

The study, which involved data from 3,113,724 patients diagnosed with 7,723,365 incident LTCs from 2015 to 2022, revealed some significant findings:

Influence of Financial Incentives: Conditions included in the Quality and Outcomes Framework (QOF), a financial incentive program, had higher rates of annual coding than those not included (1.03 vs 0.32 per year, p<0.0001).

Variability Across GPs: There was a significant variation in the frequency of coding across different General Practices, which was not explained solely by patient sociodemographic factors.

Impact of Sociodemographic factors: Higher coding rates were observed in people living in areas of greater deprivation, irrespective of whether the conditions were part of QOF or not.

Covid-19: The study noted a decrease in code frequency for conditions that had follow-up time in the year 2020, likely due to the COVID-19 pandemic affecting healthcare services.

Implications for Healthcare Providers and Researchers

The findings of the study raise some pertinent questions:

Addressing Financial Incentives: If the QOF influences coding rates, how can we ensure a level playing field for conditions not included in such programs? This could impact resource allocation and healthcare planning.

Standardizing Practices: The variability in coding across GPs implies that there might be inconsistencies in how conditions are diagnosed and recorded. These inconsistencies need to be addressed to improve the quality of healthcare.

Considering Sociodemographic factors: The influence of patient sociodemographic factors suggests a need for tailored interventions, especially in areas with higher deprivation levels.

Navigating Pandemic-related Challenges: The reduction in coding during the COVID-19 pandemic indicates that external factors can significantly affect healthcare data. This demands adaptive strategies to ensure the ongoing reliability of EHRs.

Conclusions and Future Steps

As we move towards a more data-driven healthcare system, understanding the biases in primary care EHRs becomes crucial. The study suggests that natural language processing or other analytical methods using temporally ordered code sequences should account for these biases to provide a more accurate and comprehensive picture. By doing so, healthcare providers and policymakers can better tailor their strategies, ensuring more effective and equitable healthcare delivery.

Read Identifying Potential Biases in Diagnostic Codes in Primary Care Electronic Health Records: What We Need to Know in full

Virtual consultations have increased in healthcare in recent years, especially since the onset of the COVID-19 pandemic. While telehealth offers many benefits for patients, such as convenience and increased accessibility, questions surrounding its impact on the quality of primary care persist. Our recent systematic review “The Impact of Virtual Consultations on the Quality of Primary Care” offers valuable insights into this timely and topical issue in healthcare delivery.

The primary goal of the study was to evaluate how virtual consultations are influencing the quality of primary care. The study was comprehensive, covering various diseases and utilizing six databases for identifying studies. It employed a rigorous screening process to ensure that only pertinent data was included.

Key Findings

The review included 30 studies comprising 5,469,333 participants. The results were quite revealing:

1. Effectiveness: Virtual consultations were as effective, or even more so, than traditional face-to-face consultations for managing certain conditions such as mental illness, smoking, and excessive alcohol consumption.

2. Patient-Centeredness: Four studies showed positive impacts on patient-centeredness, although patients felt a decrease in perceived autonomy support when engaging with healthcare providers virtually.

3. Efficiency: Virtual consultations might reduce waiting times, decrease patient costs, and lead to fewer follow-ups in secondary and tertiary healthcare settings.

4. Patient Safety: Unfortunately, data on the impact of virtual consultations on clinical safety was found to be extremely limited.

5. Equity: The evidence is mixed regarding the equitable use of virtual consultations. They seem to be favoured more by younger, female patients, and disparities were observed among other demographic groups depending on contextual factors.

Areas for Further Research

The study identified several gaps in the existing body of evidence. Specifically, there is a need for more robust data regarding patient safety, equity, and patient-centeredness. The researchers stress the importance of utilizing real-world data and clinical trials to ensure that virtual consultations are both effective and inclusive.

Conclusions

While the systematic review brings optimism about the effectiveness and efficiency of virtual consultations, it also flags important areas where more research is needed. A tailored approach, based on more comprehensive data, is crucial for informing future policies in virtual primary care. By focusing on these areas, healthcare providers and policymakers can aim to offer a more balanced, equitable, and safe healthcare delivery system for patients.

Read The Impact of Virtual Consultations in Primary Care in full

The Secretary of State for Health and Social Care, Steve Barclay, has confirmed the UK government is considering plans to allow patients in England to bypass their GP and directly access some diagnostic tests for suspected cancer. The clinical and cost-effectiveness of these new diagnostic pathways must be compared with alternative solutions such as investing more in core NHS general practice services. My article in the British Medical Journal discusses some of the key issues and challenges in implementing this radical new policy.

Read Direct access to cancer diagnostics: the promise and perils of bypassing GPs in full

A new article in the British Medical Journal from Carol Chan, Ana Neves and myself looks at the importance of implementation and training in the use of electronic health records (EHRs) in healthcare. The introduction of EHRs has been one of the most significant changes in how healthcare is delivered in recent decades. But while EHRs have brought many benefits to the NHS, for patients and clinicians, they have also created substantial challenges that must be addressed.

Read Electronic health records: The importance of implementation and training in full

Multimorbidity, the coexistence of multiple chronic conditions within an individual, is a growing global health challenge affecting a significant portion of the population. Patients with multimorbidity often face complex healthcare needs, leading to increased unplanned healthcare utilization. In an effort to address this issue, community-based interventions have emerged as potential solutions for providing continued care outside of traditional hospital settings. Our systematic review published in the Journal of the Royal Society of Medicine aims to summarize the impact of these interventions on unplanned healthcare use in patients with multimorbidity.

The Burden of Multimorbidity

With the prevalence of multimorbidity increasing, affecting approximately one-third of the global population, it is crucial to find effective strategies to manage this complex condition. The challenges posed by multimorbidity often result in frequent emergency department visits and hospital admissions, placing a significant strain on healthcare resources.

Community-Based Interventions

Community-based interventions offer a promising approach to address the needs of multimorbid patients. These interventions focus on delivering care in community settings, with an emphasis on education, self-monitoring of symptoms, and regular follow-ups. Additionally, some interventions aim to improve care coordination, advance care planning, and provide palliative care for patients with severe conditions. By implementing these interventions, healthcare providers seek to enhance patient self-management, reduce the burden on emergency departments, and improve overall health outcomes.

Findings from the Systematic Review

Thirteen studies, involving a total of 6148 participants, were included in this systematic review. Notably, all the studies were conducted in high-income settings and primarily focused on elderly people. The primary outcome assessed across all studies was emergency department attendance. The risk of bias was generally low across the included studies.

The results revealed that all 13 studies reported a decrease in emergency department visits following the implementation of community-based interventions. The risk reduction ranged from 0 (95% confidence interval [CI]: –0.37 to 0.37) to 0.735 (95% CI: 0.688–0.785). This suggests that these interventions have the potential to effectively reduce unplanned healthcare usage among patients with multimorbidity.

Challenges and Future Directions

Identifying specific successful components of community interventions proved challenging due to the overlaps between different interventions. However, the overall findings strongly support the integration of community-based approaches into existing healthcare structures. Policymakers should recognize the importance of these interventions and work towards their implementation to alleviate the burden on emergency departments and improve patient outcomes.

Future research must explore the impact of community interventions on a broader range of participants. This will allow for a better understanding of the effectiveness of these interventions in diverse populations and settings. By expanding the scope of research, we can gain deeper insights into the potential benefits of community-based interventions for patients with multimorbidity.

Conclusion

Community-based interventions have shown promise in reducing emergency department visits among patients with multimorbidity. These interventions empower patients to manage their conditions, promote education, and improve care coordination. Policymakers and healthcare providers should recognize the value of these interventions and work towards integrating them into existing healthcare structures. By doing so, we can enhance patient care, reduce healthcare costs, and alleviate the burden on emergency departments. As we move forward, further research is needed to explore the broader impact of community interventions and their potential to improve outcomes for patients with multimorbidity in various contexts.

Read The effects of community interventions on unplanned healthcare use in patients with multimorbidity in full