Electronic coordination for end-of-life care

Good quality palliative care depends on recording, sharing, and acting on patients’ needs and preferences, such as their wishes about resuscitation and their preferred place of death. An electronic care coordination system known as KIS (Key Information Summary) was evaluated in Scotland by Finucane and colleagues using data from over 1300 deceased patients. Their study found that patients with a KIS record were twice as likely to die in the community, as they wished, rather than in hospital, and most had a record of their desired resuscitation status. Patients with frailty and dementia frequently had a KIS recorded a year or more before their death. Optimising use of KIS can be encouraged by carrying out computer searches of practice databases and using instruments such as the SPICT to help identify people who would benefit from a palliative approach.

Cancer referral patients miss hospital appointments

A small proportion of patients referred under the 2-week-wait (2WW) policy for suspected cancer do not attend their appointments, and it appears that early mortality outcomes are worse among these patients, compared to attenders. Jefferson et al. interviewed GPs and patients who had not attended or cancelled their appointments to find out reasons for non-attendance. For some the appointment system let them down, but for others more complicated factors were involved, including patients’ fear of procedures and anxiety leading to hesitation and avoidance. GPs commented that 2WW referrals could create problems in communicating cancer risk while minimising anxiety. Organising a 2WW appointment during the normal GP appointment can be difficult. There are modifiable factors which could be addressed to improve patients’ understanding of and attendance at urgent cancer referral appointments.
 

Chest X-rays are not adequate for lung cancer diagnosis

Over 35,000 people die from lung cancer each year in the UK. Survival rates for lung cancer are poorer than for most cancers, and have not increased much over the last 20 or 30 years. NICE recommends chest X-ray (CXR) for initial evaluation in all patients with suspicious symptoms, but up until now research has not examined the sensitivity of CXR alone for lung cancer in patients with suggestive symptoms. Bradley and colleagues analysed the available research literature and conclude that the sensitivity of CXR for symptomatic lung cancer is only 77–80%. They concede that many of the studies are of poor quality, but these data are drawn from those of highest research quality. The implications for practice are that GPs, and by extension their patients, should take limited reassurance from a non-diagnostic CXR, and consider additional imaging or referral, or repeating the CXR. They suggest the possibility of widening access to more accurate investigations such as CT scanning, although the benefits of increased rates of CT investigation have to be balanced against the possibility of over diagnosis and false-positive findings.

GPs’ real-terms income is falling

There is a workforce crisis in general practice, with major concerns about retention of GPs, and insufficient numbers of trainees entering general practice to replace those leaving. These problems inevitably have an impact on services to patients. Income is a fundamental consideration affecting the attractiveness of working in general practice, and a recent large scale survey of GPs has found that incomes have fallen significantly in recent years. Atkins and colleagues found that GP partners‘ income decreased slightly between 2008 and 2017, with a greater fall in incomes for salaried GPs. At the same time the average number of sessions worked decreased from 7.7 to 7 per week for GP partners and from 5.6 to 5.3 for salaried doctors. Mean income adjusted for the sessions worked and for inflation decreased by 10% for partner GPs and 7% for salaried GPs, between 2008 and 2017. The researchers are unable to say with certainty whether these falls in income have contributed to the current problems with GP recruitment and retention.