Tag: Primary Care

Primary care update on Group A Streptococcal infections in the UK

There has been an increase Group A Streptococcal (GAS) infections in recent months, which has led to at least 8 deaths in children. Although GAS rates are higher than expected for this time of year, they have been higher at periods over the last decade. GAS causes a range of infections including Scarlet Fever and also more severe invasive disease.

For more information on management, see: Scarlet fever: a guide for general practitioners. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5649319/
The Centor score can be used to assess the probability of an illness being GAS pharyngitis: Tonsillar exudates, tender anterior cervical adenopathy, absence of cough, history of fever (>38 °C). Penicillin V (or Amoxicillin) is the preferred treatment unless contra-indicated in which case an alternative such as a cephalosporin or clarithromycin can be given.

Scarlet Fever and invasive GAS disease are notifiable and should be reported to the local health protection unit. Contacts (although at higher risk of GAS infection) do not generally need antibiotics unless symptomatic. See contact tracing flowchart for details. Health protection teams are responsible for contact tracing.

This guidance was updated in 2008 and may change again.
https://www.gov.uk/government/publications/invasive-group-a-streptococcal-disease-managing-community-contacts

Antibiotics should only be administered:
1. To mother and baby if either develops invasive group A streptococcal disease in the neonatal period (first 28 days of life);
2. To close contacts if they have symptoms suggestive of localised Group A streptococcal infection, i.e. sore throat, fever, skin infection;
3. To the entire household if there are two or more cases of invasive group A streptococcal disease within a 30 day time period.

Oral Penicillin V is the drug of first choice where chemoprophylaxis is indicated. Azithromycin is a suitable alternative for those allergic to penicillin. Some areas of England are now reporting shortages of liquid antibiotics.

Developing a shared definition of self-driven healthcare

Witing in the Journal of the Royal Society of Medicine, myself, Austen El-Osta and Chris Rowe set out a vision for building sustainable, self-driven healthcare spanning primary care, secondary care and the wider health and social care system has been set out by medical innovators. Self-driven healthcare (SDH) is an umbrella term introduced by Innovate UK, the UK’s national innovation agency, to conceptualise aspects of healthcare delivery that can support people in becoming more engaged in managing their own health and wellbeing, rather than being passive receivers of healthcare.

In our paper, we describe an SDH ecosystem that supports individuals to take more ownership of their health and wellbeing and in recording their own data (e.g. weight, blood pressure) using a phone app, tablet, computer or Bluetooth device. This self-generated data would then be uploaded onto a secure online SDH portal which holds all their health records, including those generated in the wider healthcare system.

Individuals would also enter other data such as what medication they had taken that day, the food they had eaten or the exercise they had done. They may even have a range of other devices that automatically record and upload useful information, such as environmental data about local air quality that day. A personalised dashboard would automatically present the user with their ‘digital twin’ and the portal may also be enabled to routinely offered insights and actionable advice, including microlearning and behaviour change interventions and a holistic picture of the person’s overall health and wellbeing status.

The SDH approach must create better access to all sections of the community rather than just wealthier and more technically literate individuals. It is also crucial that the SDH movement does not exacerbate inequalities due to the digital divide. How SDH is adopted in the future is very important, especially when it is applied to help enhance the consumer health system by trying to link it effectively with state-funded NHS health and social care systems. It will be important to determine if these online environments will be provided by expanding the NHS App, for example, or by commercial companies.

Multidisciplinary Team Meetings to Manage Patients with Multimorbidity in Primary Care

Our new paper in the International Journal of Integrated Care reviews the role of multidisciplinary team (MDT) meetings in the management of multimorbidity in primary care. MDTs bring together professionals to work together to improve health outcomes for patients. MDT meetings are often recommended as a critical aspect of integrated care in guidance and opinion pieces, but it is not clear how and to what extent their use improves outcomes for patients with multimorbidity. Our review aimed to fill this knowledge gap.

We found limited evidence that supports the implementation of MDT meetings in primary care settings for individuals with multimorbidity. There were also substantial problems with the methodological rigour of previous studies on MDT meetings in primary care. Although MDT meeting are a key strategy for delivering comprehensive integrated care, there is a lack of evidence concerning the efficacy of MDT meetings in primary care. The complexity of interventions meant that causality cannot be attributed to the MDT meeting alone.

There is an urgent need generate more evidence about MDT meetings in primary care. Future research should focus on a broader set of participant characteristics, contextual adaptation, and innovation. Decision makers and clinicians should also take advantage of the recent technological progress in healthcare.

Why is FIT important for people with lower gastrointestinal symptoms?

If you consult your doctor about bowel symptoms, they may speak about getting FIT. What is FIT? In this context, it is nothing to do with exercise or how far you can run. FIT stands for faecal immunochemical test, which aims to detect blood in your faeces. The test is highly sensitive.

People with lower bowel symptoms such as a change in their bowel habits will understandably be concerned about the possibility of bowel cancer. The risk of colorectal cancer in people with a negative FIT, a normal examination and normal full blood count is <0.1%. This is lower than the general population risk of colorectal cancer. So this combination of clinical findings allows your doctor to conclude that you are very unlikely to have bowel cancer. However, many people with lower GI symptoms still do not undergo FIT before referral to a specialist.

Patients with a FIT of fHb <10μg Hb/g, a normal full blood count, and no ongoing clinical concerns do not need to be referred on a lower GI urgent cancer pathway but can be managed in primary care or referred on an alternative pathway with suitable safety netting if symptoms change. FIT can improve patient management. By fully implementing the use of FIT in people with lower GI symptoms in primary care, we can spare patients unnecessary colonoscopies, releasing capacity to ensure the most urgent symptomatic patients are seen more quickly in specialist clinics.

There are some patients for whom FIT is not suitable, such as those with iron deficiency anaemia, a rectal or anal mass, or anal ulceration. See below for further guidance on the use of FIT in people with lower GI symptoms.

https://www.england.nhs.uk/wp-content/uploads/2022/10/B2005_i_Using-faecal-immunochemical-testing-lower-gastrointestinal-pathway_primary-care-letter.pdf

https://www.bsg.org.uk/clinical-resource/faecal-immunochemical-testing-fit-in-patients-with-signs-or-symptoms-of-suspected-colorectal-cancer-crc-a-joint-guideline-from-the-acpgbi-and-the-bsg/

Why we need to put an end to the GANFYD culture in the UK

One of the causes of increased workload in general practice are the many requests that doctors get for letters from patients or from external organisations. It’s now so common that doctors have coined a term for it: GANFYD – Get A Note From Your Doctor.

It’s seems that large sections of society can’t function without these “letters from doctors”. Instead of using common sense or employing their own clinical advisers, external organisations make repeated requests to NHS doctors for letters which are not at all needed.

Often the worst offenders come from the public sector – e.g. universities who seem to look upon NHS general practice as a source of free occupational health advice for their students. Universities never – of course – offer to pay for this advice they get from NHS GPs.

Instead, university requests will come with a mealy-mouthed statement that any fee is the responsibility of the student. Like doctors are going to impose heavy fees on impoverished students who already have large debts and are who are often living in poverty.

Local government and schools are other frequent offenders, requesting letters for issues they could easily resolve themselves using some common sense. And perhaps surprisingly, the NHS is also a frequent offender (you would think that NHS Trusts would know better).

What’s the solution? I have concluded that to address the GANFYD problem, we need to remember the adage “money talks while bullshit walks”. But don’t charge patients. Change NHS regulations so the (suitably large fee) is the responsibility of the organisation making the request.

The NHS is under great pressure and we urgently need to do everything we can to reduce unnecessary work in the NHS so that NHS staff can focus on clinical work.

General practitioner perceptions of using virtual primary care during the COVID-19 pandemic

Whether it be a simple telephone call or more sophisticated video conferencing systems, virtual care tools have been in use in primary care settings worldwide in one form or another throughout the past two decades. Over time, these tools have grown in availability, matured in their capabilities, but played a largely supportive role as an alternative option to traditional face-to-face consultations. This all changed in early 2020 with the onset of the COVID_19 pandemic.

The COVID-19 pandemic presented a unique opportunity globally which put virtual care tools at the forefront of primary care delivery. The need for social distancing to limit disease transmission resulted in virtual care tools becoming the primary means with which to continue providing primary care services. Hence, our study’s goal was to capture the spectrum of GP experiences using virtual care tools during the initial months of the pandemic so as to better understand the perceived benefits and challenges, and explore what changes are needed to allow them to reach their fullest potential.

We carried out a global study to investigate this further, published in the journal PLOS Digital Health. We received 1,605 responses from 20 countries globally. Our results demonstrated that virtual care tools were beneficial in limiting COVID-19 transmission, improved convenience when communicating with patients, and encouraged the further adoption of virtual care tools in primary care. Challenges included patients’ preferences for face-to-face consultations, digital exclusion of certain populations, diagnostic challenges associated with the inability to perform physical examinations, and their general unsuitability for certain types of consultations. Practical challenges such as higher workloads, payment issues, and technical difficulties were also reported.

Learning from this global natural experiment is critical to both updating existing and introducing new health technology policies concerning virtual primary care. Doing so will be imperative to supporting and promoting the better use of these novel technologies in our evolving healthcare milieu.

DOI: https://doi.org/10.1371/journal.pdig.0000029

Should GPs in England be employed by the NHS?

The intense micromanagement of general practices by NHS England since the start of the Covid-19 pandemic in early 2020 has shattered the illusion that NHS general practitioners are truly “independent”. For example, during the pandemic, NHS general practices have often received weekly updates from NHS England on how they should provide primary care services.[1] The opening hours and working arrangements of general practices are also highly regulated by NHS England. And general practitioners are not independent contractors in the same way that professionals working in other fields or indeed primary care physicians working overseas would recognise. General practitioners are not even able to offer private medical services to their patients in the same way as NHS Trusts or dentists are able to do. In effect, they have all the disadvantages of being self-employed contractors and none of the benefits of being NHS employees.

For more than a decade, primary care in England has suffered from under-investment, and a lack of key staff such as general practitioners and practice nurses. The NHS hospital sector in contrast – although it also has its problems – has seen its funding and medical staffing increase at a much quicker rate than in NHS primary care.[2] And yet despite this, more NHS work continues to be shifted to primary care without being followed by a commensurate increase in funding and staffing. Attempts by NHS England to prevent this – such as the introduction of the NHS Hospital Contract – have failed.[3] It’s very clear that NHS England is not going to invest adequately in the current independent contractor model of general practice, making being a GP Partner increasingly unattractive for younger general practitioners.[4] It’s time therefore to look seriously at the alternative – GPs becoming salaried employees of the NHS.

Of course, being employed by the NHS is not a panacea. Many NHS staff employed by NHS Trusts suffer from stress and over-work, just like those working in primary care. But they are not personally responsible for the ownership of their employing organisations, and their income does not depend on how well their organisation performs financially. Their working hours are also better regulated than those of self-employed GPs.

If GPs had employment contracts similar to those of NHS consultants, they could then have job plans with time allocated for activities such as quality improvement, NHS management, teaching, training, and research. Currently, these activities are often done on top of their regular working hours. Working in organisations that employed large numbers of GPs would also create opportunities for a better career structure. For example, it may be possible to create posts for GPs who specialise in areas such as the care of the elderly or in child health; and for GPs who take on clinical leadership, quality improvement and NHS management roles in addition to a clinical role.[5]

Finally, GPs becoming NHS employees would make NHS England directly responsible for the delivery of primary care services, in the same way they already are for specialist services. It would be the responsibility of NHS England – not GPs – to ensure that patients had timely access to a comprehensive range of high-quality primary care services and the infrastructure needed to deliver this care.

An increasing proportion of NHS GPs are already salaried. The future for GPs therefore looks to be heading in this direction. The question for GPs is do they want to be employed by the NHS with similar terms of employment to consultants; or do they want to be employed by private companies and “mega-partnerships” with the inevitable variability in terms of employment that they will offer?

A version of this article was first published in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.o406

References

1. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. Journal of the Royal Society of Medicine. 2020;113(6):208-210.

2. Anderson M, O’Neill C, Clark JM, Street A, Woods M, Johnston-Webber C, et al. Securing a sustainable and fit-for-purpose UK health and care workforce. The Lancet. 2021 May 22;397(10288):1992-2011.

3. Price A, Majeed A. Improving how secondary care and general practice in England work together: requirements in the NHS Standard Contract. Journal of the Royal Society of Medicine. 2018;111(2):42-46.

4. Rimmer A. GPs move towards industrial action after rejecting “rescue plan” for general practice BMJ 2021; 375:n2594

5. Majeed A, Buckman L. Should all GPs become NHS employees? BMJ 2016; 355:i5064

General Practice in England: The Current Crisis, Opportunities and Challenges

General practice or family medicine has historically been lauded as the “jewel in the crown” of the English National Health Service (NHS). General practice, at the heart of primary care, has continued to contribute to the high ranking of the NHS in international comparisons and evidence from several decades of research has shown that general practice in the UK has improved the nation’s health. Furthermore, it has provided equitable, cost-effective, and accessible care for all with the flexibility to adapt rapidly to a changing society and political climates, such as during the COVID-19 pandemic when there was rapid implementation of remote consultation models. However, this much-admired public sector service has recently come under unprecedented political and media spotlight instigated by the pressures of the current pandemic on the NHS. This coupled with collapsing morale among general practitioners (GPs), a shrinking GP workforce, inexorable demands, increasing workload, and decreasing real-terms per capita funding have caused many to sound alarm on a general practice in “crisis”. In this article published in the Journal of Ambulatory Care Management, we describe the evolving nature of general practice and the current crisis, as well as potential solutions and opportunities going forward.

The full article can be read in the Journal of Ambulatory Care Management.

DOI: 10.1097/JAC.0000000000000410

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