RCGP Research Paper of the Year 2017: of relevance to the General Practice Forward View?

The Research Paper of the Year (RPY), awarded by the Royal College of General Practitioners (RCGP), gives recognition to an individual or group of researchers who have undertaken and published an exceptional piece of research relating to general practice or primary care. The award spans six categories, with one overall winner.

This year, for the 2017 award, we had 72 submissions. The support provided by the RCGP’s Clinical Innovation and Research Centre (CIRC) ensured that the judging process was efficient — I hope the members of the six sub-panels, who gave up their time for judging papers, agree. The panel at which we discussed the overall winner was co-chaired by Jonathan Mant, due to my conflict of interest on two papers — thank you, Jonathan.

It might be useful to reflect on the relevance of the winning papers to the General Practice Forward View ¹ (GPFV), which, when published in 2016, emphasised the interests of GPs and their patients at the heart of all proposals.

The GPFV referred to the low morale due to the ‘daily struggle with growing workload’ (page 8). The paper winning the Mental Health category of RPY category 4, (Neurology, Mental Health, and Dementia), and published in the British Journal of General Practice, describes the barriers and facilitators that face GPs as they consider seeking treatment for distress, as well as exploring the ways in which they may protect themselves from workplace stresses.² Joanna Spiers says: ‘The GP Forward View cites excessive workload as being the main pressure in general practice. Our work suggests that this pressure may contribute to GPs feeling that they must attend work even if they are sick, and this attitude was also a major barrier to help-seeking. GP participants discussed cutting down their hours to protect their mental health. While this strategy may be successful on an individual level, it has worrying implications for the profession which is already dealing with falling numbers of practitioners.’

This research team has donated the RPY award to the Cameron Fund (http://www.cameronfund.org.uk), which is the only medical benevolent fund that solely supports GPs and their dependants in times of financial need, whether through ill health, disability, death, or loss of employment.

A key chapter in the GPFV was ‘workforce’, emphasising the expansion of the primary care workforce and broadening the skill-mix. Wynne-Jones’s paper³ reports the evaluation of a vocational advice service located in general practice for patients with musculoskeletal pain. Winner of RPY category 5 (Health Service Delivery and Public Health), Gwen Wynne-Jones observes: ‘The SWAP trial is innovative in providing support to GPs in managing occupational health problems through early access to appropriate advice and support for patients who are absent from work. With the Forward View’s commitment to ensuring that the wider multidisciplinary team have the skills to complement those of GPs, developing the role of the vocational advisor to provide more comprehensive and timely occupational health support would be of benefit to primary care clinicians, patients and society more broadly.’

The GPFV emphasises the key role of information technology in supporting patient care, and risk scores generated by our patient record systems are already embedded in our routine care. The winning paper in category 2 (CVD, Renal, Respiratory, Oral, ENT, and Ophthalmology) demonstrates that QRISK3, the updated prediction tool for cardiovascular disease, can identify more people at risk.⁴ Julia Hippisley-Cox says: ‘QRISK3 enables patients at highest risk of heart disease and stroke to be identified and offered interventions to lower their risk. It also enables busy clinicians to share more personalised information about risk with patients to enable shared decision-making. The new QRISK3 tool includes 8 additional risk factors including severe mental illness and learning disabilities, people who would otherwise have their risk under-estimated leading to lost opportunities for prevention.’

Utilising patient records in the Clinical Practice Research Datalink (CPRD), Morgan et al⁵ provide evidence about the rising incidence of self-harm in children and adolescents. Referrals to specialist mental health services within 12 months of the self-harm event were 23% less likely for young patients registered in practices in the most deprived areas, even though the rates of self-harm were higher in these areas. Cathy Morgan, lead author of the winning paper in category 3 (Children, Reproduction, Genetics, and Infections), reflects on the need for more integration between services, as emphasised in the GPFV: ‘The most striking finding from our study was the 68% rise in self-harm incidence among girls aged 13–16 years between 2011 and 2014. This finding highlights the urgency to improve GPs’ access to Child and Adolescent Mental Health services to ensure safety among all distressed young people and secure their future mental health and wellbeing.’

This paper has already had an impact on commissioning, being mentioned in the government green paper on mental health in children and young people.⁶ The research team has donated its prize to 42nd Street (http://42ndstreet.org.uk), a third-sector organisation in Manchester that offers support for young adults with mental health problems.

The paper that won category 1 (Cancer) reports that a raised platelet count, thrombocytosis, is an important marker of undiagnosed cancer and worthy of further investigation for underlying malignancy.⁷ The GPFV reflects on the need for integrated referral pathways, which would thus need to take this important finding into account. Lead author Sarah Bailey notes: ‘We found that thrombocytosis, a raised platelet count, is an important sign of cancer, particularly in men aged over 40. As the platelet count is measured as part of a full blood count, our findings can be of immediate clinical use. This is the first new symptom of cancer to be discovered in 30 years and it holds real hope for achieving earlier diagnosis of cancer.’

This paper should have an immediate impact on primary care, and has the potential to change the practice of every GP and, potentially, lead to earlier cancer diagnosis.

The GPFV further highlights the need to manage demand and reduce unnecessary workload — not doing work that is not evidence based. The winning paper in category 6 (Endocrinology, including Diabetes, Gastroenterology, Musculoskeletal and Trauma, and Dermatology), and overall winner of RPY, was a systematic review⁸ which showed that HbA1c is neither sensitive nor specific for detecting pre-diabetes; fasting glucose is specific but not sensitive. These investigations are ordered on a daily basis by GPs, but the authors suggest that many people will receive an incorrect diagnosis and be referred on for interventions, whereas others will be falsely reassured and not offered any advice or intervention. Eleanor Barry states: ‘Type 2 Diabetes adds substantially to the NHS and GP workload, whilst being a life-changing condition for patients. Our paper identifies the limitations of current prevention policies in screening for people at risk of diabetes with blood tests and treating them with individual lifestyle interventions. To ensure the success of primary prevention policies, interdisciplinary working across sectors to address upstream influences will be required to supplement individual-level prevention strategies.’

This paper was judged to be the overall winner because of the relevant (and, the judging panel suggested, surprising) results that could change practice; in addition, the paper presented very complex work in a readable way.

These papers are all great examples of how research arising from general practice can lead to innovation in general practice and ultimately to improvement in patient care — the fundamental priority of the GPFV.

Of course, the main thrust of the GPFV was an emphasis on the need for significant investment in general practice — the report released in August 2018,⁹ reviewing the GPFV at 2 years, suggests that the ambitions of the GPFV are not yet being realised.

• © British Journal of General Practice 2018