Better dementia diagnosis – at a price?

A national Dementia Strategy was introduced in 2009 to encourage earlier diagnosis of dementia. This led to two voluntary financial incentive schemes in general practice to facilitate timely diagnosis and support for dementia. In an analysis of 7079 English primary care practices by Dan Liu and colleagues from the University of York and the London School of Economics, the two schemes were both associated with a positive impact on quality outcomes for dementia measured by the Quality Outcomes Framework. Researchers found that the schemes had beneficial effects on the care of other long-term conditions, but also sounded a warning note: there seemed to be some adverse outcomes on several aspects of patient experience, including reduced patient centredness, continuity of care, access to care, and confidence and trust in the GP. Practices may have diverted efforts towards assessments for dementia, reducing the time available for other patients.

The state we’re in

The General Medical Council's eighth annual report on The state of medical education and practice in the UK 2018 puts support, retention, and supply of doctors for the future at the very centre of its priorities, commenting that the UK is running out of time to prevent a significant decline in workforce numbers, which risks patient safety. The report takes a close look at the problems facing the medical workforce and the pressures on individuals working in the system. It contains a call to action in the healthcare sector for a commitment to new ways of thinking about how workforce supply can be achieved, and how workforce strategies in all four countries of the UK need to set out clear plans for ‘making the UK a great place to work for doctors’. The idea of a call for action is taken up in an Editorial by Sanju George and Clare Gerada who trace the implications of this report for general practice.

Warning signs of laryngeal cancer

In an analysis of over 800 patients diagnosed with laryngeal cancer, Shephard and colleagues from the University of Exeter found that symptom combinations may have a higher predictive value for a cancer diagnosis than single symptoms alone. The predictive value of persistent sore throat plus either dysphagia, dyspnoea, or otalgia is greater than 5%, compared with the predictive value for hoarseness alone of 2.7%. Patients with hoarseness and abnormal inflammatory markers on blood testing have a particularly high (15%) likelihood of cancer. 

Professor Willie Hamilton, one of the authors, explains: ‘This research matters – when NICE guidance for cancer investigation was published there was no primary care evidence to guide NICE, or GPs. Crucially, hoarseness serious enough to be reported to GPs does warrant investigation. Furthermore, some symptom combinations previously thought to be low-risk are now shown to matter.’

General practice has been getting a bad press

In an analysis of over 400 news articles on general practice and 100 on hospital specialties, general practice articles depicted the service as being in crisis, with low morale, high burnout, and gaps in patient care. GPs were portrayed as being responsible for the crisis and the resulting negative impact on patient care. Hospital specialties were also illustrated as being under pressure, but the crisis was depicted as being the fault of the government. GP leaders were reported as usually defending their specialty, while hospital doctors were usually sharing their expertise. Researchers Eleanor Barry and Trish Greenhalgh from the University of Oxford comment that there is a need to counter the depiction of general practice as disorganised and inefficient, and that realistic messages about the funding crisis need to be conveyed. Organisation of primary care services to compensate for the worsening GP shortage could and should be depicted in a more positive light. Further research is needed to understand how these negative media messages can be countered and replaced by a more evidence-based picture of primary care.