Gout in primary care: can we improve patient outcomes?
DOI: 10.3399/bjgp19X703289
Background
Gout is a red flag indicator for cardiovascular disease and comorbidity. Despite this, there are no incentivised treatment protocols and suboptimal management in the primary care setting is common.
Aim
Improvement cycles aimed to educate patients, improve uric acid monitoring, and support medication compliance. It was ultimately hoped that these measures would reduce gout flares and GP practice attendance.
Method
A computer-based retrospective search at a large inner-city GP practice between January 2014–December 2014 identified 115 patients with gout. Baseline measurements revealed multiple gout related consultations, poor medication compliance, high uric acid levels, and deficiencies in uric acid monitoring. All patients in the cohort received a telephone consultation regarding their gout followed by a diet, lifestyle, and advice sheet in the post. A new gout phlebotomy order set was devised to include full blood count, urea and electrolytes, cholesterol, urate, random blood sugar, and HbA1c. Letters were sent out to arrange for these blood tests in patients who had not received them during the previous 12 months.
Results
The improvement cycles contributed towards reduction in uric acid levels from 0.37 to 0.3 (P = 0.14), 20% reduction in patients experiencing one or more gout flares, and 77% reduction in GP related consultations between March 2015 and March 2016 compared to baseline. The proportion of patients fully compliant with taking their urate lowering therapies improved from 63% to 91% (P = 0.0001).
Conclusion
The improvement and Plan, Do, Study, Act cycles have demonstrated that simple interventions can be a sustainable way of improving disease control and patient outcomes.
Georgina Blakey, Royal United Hospital
Email: georgina.blakey{at}nhs.net
Jacqueline Callear, Sloan Medical Centre
Determinants of influenza and pertussis vaccination uptake in pregnancy: a multi-centre questionnaire study of pregnant women and healthcare professionals
DOI: 10.3399/bjgp19X703301
Background
Uptake rates of influenza and pertussis vaccination in pregnancy remain suboptimal.
Aim
To determine the acceptability of routine vaccination among pregnant women; the confidence of maternity healthcare professionals (HCPs) discussing vaccination; and HCP opinion with regards to the optimum healthcare site for vaccine administration.
Method
Separate questionnaires for pregnant women and maternity HCPs were distributed within four NHS trusts in South England from July 2017–January 2018.
Results
Responses from 314 pregnant women and 204 HCPs (18% obstetricians, 75% midwives [both hospital and community], 7% unidentified) were analysed. Actual/intended uptake of influenza and pertussis vaccination was 78% and 92%, respectively. The commonest reason for declining vaccination was feared side effects for their child. White British women (79%) were significantly more accepting of influenza (odds ratio [OR] 3.25, 95% confidence interval [CI] = 1.67 to 6.32) and pertussis vaccination (OR 4.83, 95% CI = 1.77 to 13.19) compared with non-white British women. Among HCPs, 25% were not-at-all or slightly confident discussing vaccination. Obstetricians felt significantly more confident discussing pertussis vaccination than midwives (OR 2.05, 95% CI = 1.02 to 4.12). Among HCPs, 53%, 25%, and 16% thought vaccines should be administered in primary care (general practice), community midwifery, and the hospital setting, respectively.
Conclusion
Misconceptions exist regarding safety and efficacy of maternal vaccination, and framing information towards safety for the child may increase uptake. Education of HCPs is essential, and vaccine promotion should be incorporated into routine antenatal care, with an emphasis on women from ethnic minorities. Administration of vaccines in primary care may present a logistical barrier to women, however support for alternative sites appears low among HCPs.
Christopher Wilcox, University Hospital Southampton NHS Foundation Trust
Email: christopher.wilcox{at}doctors.org.uk
Anna Calvert, St George’s, University of London
Jane Metz, University of Bristol
Eliz Kilich, St George’s, University of London
Rachael Macleod, University of Bristol
Kirsten Beadon, University of Oxford
Paul Heath, St George’s, University of London
Asma Khalil, St George’s, University of London
Adam Finn, University of Bristol
Matthew Snape, University of Oxford
Tushna Vandrevala, University of Kingston
Tom Nadarzynski, University of Westminster
Matthew Coleman, University Hospital Southampton NHS Foundation Trust
Christine Jones, University of Southampton
C-reactive protein testing reduces antibiotics prescription in a community setting
DOI: 10.3399/bjgp19X703313
Background
Overuse of antimicrobials and the threats posed by resistance are concerning. Most patients in primary care with respiratory tract symptoms are prescribed antibiotics, amounting between 80–90% of all prescriptions. The National Institute for Health and Care Excellence (NICE) recommends point-of-care (POC) testing of C-reactive protein (CRP) where there is uncertainty about prescribing antibiotics. Studies evaluating the use of POC CRP to reduce antibiotic prescribing for self-limiting respiratory illness in primary care have demonstrated heterogeneity in their results.
Aim
To evaluate the impact of POC CRP testing on antibiotic prescribing.
Method
A retrospective case analysis was undertaken at a GP practice. Alere Afinion AS100 was used for POC CRP testing. Data were collected on patients presenting with cough or sore throat who had POC CRP testing used in their clinical decision making. Eighty-four cases were selected for inclusion. NICE clinical guideline CG191 was used as a standard comparator for antibiotic prescribing and patients were followed up over a 2-month period.
Results
Patients presented with cough (n = 56) and sore throat (n = 28). At initial presentation 23/84 (27.4%) of patients were prescribed antibiotics. Over the 2-month follow-up period 15/84 (17.8%) of patients had at least one further consultation related to their initial respiratory complaint with 6/84 (7.1%) being prescribed antibiotics. The overall effect was a reduction of antibiotic prescriptions by 65.5%.
Conclusion
The use of POC CRP testing helped GPs reduce the rate of antibiotic prescription and improve antimicrobial stewardship by being an addition to their diagnostic armoury. It has also shown potential role in patient reassurance and modifying health seeking behaviour.
Abdus Burahee, University Hospitals Birmingham Foundation Trust
Email: abdus.burahee{at}nhs.net
Owen Hibberd, University Hospitals Birmingham Foundation Trust
Aneja Malladi, River Brook Medical Centre, Birmingham
MEMORABLE: MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation
DOI: 10.3399/bjgp19X703325
Background
Older people are major users of medication. As people get age, the balance between benefits and harms for medication changes. Medication management by healthcare practitioners (for example, pharmacists, doctors, and nurses) is designed to help older people take the appropriate medication. Current evidence indicates that medication management is a complex process that is not easy to do well.
Aim
The aim of MEMORABLE, funded by the NIHR, is to understand how medication management works and how it might be implemented effectively.
Method
MEMORABLE uses realism to understand how, why, for whom, and in what circumstances medicines management works. Realism is a theory-driven approach using primary and secondary data to make sense of complex interventions (for example medicines management), where outcomes are context sensitive. This is the first-time worldwide that realism has been used for this long-standing problem. MEMORABLE uses the literature (secondary data) and interviews (primary data). Data will be synthesised across datasets to set out and refine programme theories, about how medication management works, and develop a framework to improve practice.
Results
Three candidate programme theories (older people, informal carers, and practitioners) were identified from the literature and interviews. These programme theories will be explored against a 5-stage medication management process, conceived as a framework for analysis of the data. Emerging mechanisms of interest, burden, capacity, and needs/concerns are being explored.
Conclusion
MEMORABLE, which ended in December 2018, is using an innovative methodology, applied collaboratively, to develop an outcome-focused, evidence-based framework enhance medication management.
Ian Maidment, Aston University on behalf of the MEMORABLE team
Email: i.maidment{at}aston.ac.uk
Management of type 2 diabetes in general practice in Ireland: effect of the ‘Cycle of Care’ programme
DOI: 10.3399/bjgp19X703337
Background
Diabetes is a major cause of death and disability worldwide and is associated with vascular complications, which are reduced by control of risk factors. The introduction of the diabetes ‘cycle of care’ pay-for-performance programme in Ireland in January 2016 means that GPs have been resourced to provide structured care to patients with type 2 disease.
Aim
To examine the effectiveness of the ‘cycle of care’ programme.
Method
A computerised search was developed for diabetes data. Forty-one practices returned data for a 12-month period before (2014) and after (2017) the introduction of the ‘cycle of care’. International guidelines informed the analysis.
Results
In total, 3189 patients were examined from 41 practices for the years 2014 and 2017. Nine practices were located in an urban setting (22%), 16 rural (39%), and 16 in a mixed location (39%); 1781 males (55.8%) and 1408 females (44.2%). In 2017, the mean age of participants was 68.5 years (standard deviation [SD] = 12.3) and 2277 (71.4%) patients had clinical data provided for both 2017 and 2014, 875 (27.4%) for 2017 only, 5 (0.2%) for 2014 only, and 32 (1.0%) for neither year. Substantial improvements in rates of recording and in levels of missing data were shown for HbA1c, lipids, renal function, blood pressure, and body mass index. Rates of foot review, retinopathy screening, treatment review, influenza immunisation, and patient education were recorded for the first time in 2017.
Conclusion
The ‘cycle of care’ programme has resulted in substantial improvements in type 2 diabetes care in Ireland, supporting pay for performance.
Raymond O’Connor, Department of General Practice, Graduate Entry Medical School, University of Limerick
Email: raymond.oconnor{at}ul.ie
Rory O’Driscoll, Kenmare Medical Centre
Jane O’Doherty, Department of General Practice, Graduate Entry Medical School, University of Limerick
Aoife O’Neill, PhD Candidate, Department of Mathematics and Statistics, University of Limerick
Conor Teljeur, Health Information and Quality Authority, Dublin
Andrew O’Regan, Department of General Practice, Graduate Entry Medical School, University of Limerick
Potentially inappropriate medications in older patients based on Beers criteria at a large family medicine clinic in Saudi Arabia
DOI: 10.3399/bjgp19X703349
Background
The use of potentially inappropriate medications (PIMs) is an issue especially among older patients who have medical comorbidities. They are more at risk to drug adverse effects compared to younger patients.
Aim
To determine the prevalence of PIMs use according to Beers criteria among the older population in a large family medicine setting in Saudi Arabia and to identify the associated risk.
Method
This was a prospective cross-sectional study conducted from June 2017 to June 2018. All patients aged ≥65 years who were followed-up at the family medicine clinics were included. The American Geriatrics Society 2015 Updated Beers Criteria were used to determine the PIMs use.
Results
A total of 270 older patients aged 72.41 ± 6.23 years were included in the study. The prevalence of PIMs was 60.7%. Multivariate analyses identified three independent variables associated with PIMs: incremental age per 5 years (odds ratio [OR] = 1.47; 95% confidence interval [CI] = 1.15 to 1.88; P = 0.002), female sex (OR 1.95; 95% CI = 1.10 to 3.42; P = 0.021), and polypharmacy (OR 8.21; 95% CI = 4.58 to 14.7; P<0.001). The most common PIMs used were 39.4% related to proton pump inhibitors (PPIs), 25.2% to diuretics (other than spironolactone), 10.6% to non-steroidal anti-inflammatory drugs (NSAIDs), and 8.7% to aspirin use.
Conclusion
This study showed high prevalence of PIMs. Increasing age, female sex, and polypharmacy were found to be significant risk factors for PIMs use. The present study reinforces the importance of comprehensive medication management and reviews. Future research should evaluate interventions aimed at improving primary care follow-up and reducing the prevalence of PIMs.
Atheer Alturki, King Saud Medical City
Email: atheeralturki{at}gmail.com
Trends in reported incidence of erectile dysfunction, hypogonadism, PDE5i prescriptions and TRT in patients with type 2 diabetes in primary care
DOI: 10.3399/bjgp19X703361
Background
Erectile dysfunction (ED) and testosterone deficiency (TD) are complications of type 2 diabetes mellitus (T2DM), and predictors of cardiovascular disease. Guidelines recommend that men with T2DM are assessed and treated for ED/TD, which was included into the Quality and Outcomes Framework (QOF) from 2013–2014 only.
Aim
Explore the effects of QOF on ED/TD diagnoses and management in T2DM patients.
Method
The study population included males (≥18 years) with T2DM and contributing to UK GP electronic health records from 1999–2016. Adjusted incidence rate ratios (IRRs) were estimated using multivariable Poisson regression.
Results
In total 135 342 adult males (mean age 60 years) with T2DM were included. During follow-up, 60 819 (45%) had a recorded ED assessment, 23 834 (18%) an ED diagnosis and of these 73% received a phosophodiesterase-5 inhibitor (PDE5i). ED assessments increased from 7.6 per 1000 PYAR in 2012 (95% confidence interval [CI] = 7.0 to 8.3) to 620 in 2013 (95% CI = 614 to 626) when included into QOF but dropped to 59.4 (95% CI = 56 to 63) in 2016. Compared with 2012, the adjusted incidence of recorded ED diagnoses and PDE5i prescriptions doubled in 2013 (incidence rate ratio [IRR] 2.0; 95% CI = 1.8 to 2.1) before falling to below pre-QOF levels in 2016 (IRR 0.89; 95% CI = 0.82 to 0.97). Of 1187 diabetic men diagnosed with ED or receiving a PDE5i in 2015, 213 (18%) had minimum one testosterone measurement, of which 45 (21%) met criteria for hypogonadism (testosterone ≤8nmol/l). Nine (20%) subsequently received testosterone replacement therapy (TRT).
Conclusion
To improve diagnosis and management of ED/TD in T2DM patients and thereby (cardiovascular) health and quality of life, incorporation of guidelines into a GP framework and/or financial incentives may be required alongside GP education.
Patricia Schartau, King’s College London
Email: patricia.schartau{at}nhs.net
Laura Horsfall, University College London
Irwin Nazareth, University College London
Mariam Molokhia, King’s College London
Michael Kirby, University of Hertfordshire
Manuj Sharma, University College London
How the Health and Social Care Act 2012 has affected commissioning of mental health in England
DOI: 10.3399/bjgp19X703373
Background
NHS mental health services are under pressure due to chronic underfunding and constrained resources. The Health & Social Care Act implemented an extensive restructure of the NHS and introduced three new legal duties: duty to arrange, promote competition, and integrate services.
Aim
To establish how the Health and Social Care Act 2012 affected commissioning of mental health services in England and how the duties are being fulfilled.
Method
Freedom of Information (FOI) requests were sent to all 211 clinical commissioning groups in England. The number, value, and length of all contracts for mental health services were requested from 2013 to 2016 by type and name of provider; as well as a range of quality and performance data.
Results
The FOI received a 93% response rate. CCGs commissioned between 1–127 contracts each: 65.3% of all contracts were awarded to the third sector (private for profit, not for profit, and voluntary organisations), amounting to 6% of the total value of contracts commissioned. NHS foundation trusts were awarded 25% of contracts, worth 70% of the total value of contracts. 71% of contracts had no evidence of quality monitoring.
Conclusion
The high volume and low value of contracts commissioned to third sector organisations fulfils the new duty to arrange but not to integrate; showing considerable fragmentation of mental health provision. The emerging external market is a result of the Health & Social Care Act promoting diversification of the provider market. Finally, the lack of quality and performance data raises concerns over the transparency and accountability of an NHS that is increasingly being provided by companies.
Alisha Patel, Addenbrookes Hospital
Email: alishapatel{at}msn.com
Transforming community nursing services in the UK: lessons from a participatory evaluation of the implementation of a new model of community nursing in East London
DOI: 10.3399/bjgp19X703385
Background
Buurtzorg, a model of community nursing conceived in the Netherlands, is widely cited as a promising and evidence-based approach to improving the delivery of integrated nursing and social care in community settings.
Aim
This study aimed to examine the transferability of some of the principles of the Buurtzorg model to community nursing in the UK NHS.
Method
A community nursing model based on the Buurtzorg approach was piloted between June 2017 and August 2018 with a team of nurses co-located in a single general practice in the Borough of Tower Hamlets, East London. The initiative was evaluated using a qualitative approach within the participatory Researcher-in-Residence model. Participant observation of meetings and semi-structured interviews with team members, patients/carers, and other local stakeholders were undertaken. A thematic framework analysis of the data was carried out.
Results
Patient experience of the service was positive, in particular because of the better access, improved continuity of care and longer appointment times in comparison with traditional district nursing provision. However, certain aspects of the Buurtzorg model were difficult to put into practice in the NHS because of significant cultural, human resource, and regulatory differences between The Netherlands and the UK.
Conclusion
While many of the principles of the Buurtzorg model are applicable and transferable to the UK, in particular promoting independence among patients, improving patient experience, and empowering frontline staff, the successful embedding of these aims as normalised ways of working will require a significant cultural shift at all levels of the NHS.
Mirza Lalani, University College London
Email: m.lalani{at}ucl.ac.uk
Jane Fernandes, East London Foundation Trust
Richard Fradgley, East London Foundation Trust
Caroline Ogunsola, East London Foundation Trust
Martin Marshall, University College London
Routine consultations for dermatology problems in adults in general practice: cross-sectional study
DOI: 10.3399/bjgp19X703397
Background
Dermatological conditions present frequently in general practice, and treatment failure is common due to low adherence with treatments. There has been little research exploring GP consultations for skin problems.
Aim
To describe consultations for skin problems in adults including shared decision making (SDM) around treatment decisions, delivery of self-management advice, and follow-up.
Method
Data were extracted from the One in a Million Study, an archive of 327 videorecorded routine GP adult consultations and linked data. A coding instrument was developed and refined, which was applied to all consultations where a skin problem was identified as having been discussed. SDM was assessed using OPTION. Twenty per cent of the consultations were double coded and inter-rater reliability assessed. Data were analysed using Stata, with descriptive statistics reported.
Results
In total 45 consultations (13.8%) were examined, featuring a mean of 2.2 problems. Of the 100 problem types, 51 were dermatological. Mean time spent on skin problems was 4:16 minutes (29.6% of total duration of consultations with ≥2 problems). SDM for skin problems was low, with mean OPTION score of 10.7 (range 0–35). Self-management advice was given for 47.1% of skin problems (verbal only). Most skin problems (84.3%) were not referred to secondary care; 32.6% of skin problems not referred were seen again in primary care within 12 weeks of the index consultation, of which 35.6% were unplanned.
Conclusion
Skin problems commonly present alongside other complaints. SDM and self-management advice are uncommon. While most dermatological problems are not referred, patients often re-consult for the same problem.
Emma Le Roux, Population Health Sciences, University of Bristol
Email: emma.leroux{at}bristol.ac.uk
Peter Edwards, Population Health Sciences, University of Bristol
Emily Sanderson, Population Health Sciences, University of Bristol
Rebecca Barnes, Population Health Sciences, University of Bristol
Matthew Ridd, Population Health Sciences, University of Bristol
The outcomes of triaging rheumatology referrals at a single point of access
DOI: 10.3399/bjgp19X703409
Background
East Surrey Clinical Commissioning Group established a musculoskeletal triage service for primary care referrals in December 2017 in order to reduce pressure on secondary care.
Aim
To analyse the processing of rheumatology referrals through the single point of access.
Method
A total of 158 referrals over an 8-month period were triaged, 50 of which had available final outcome data. Using a standardised form for GPs, data including initial GP diagnosis, appropriateness for secondary care, any requirement for additional information, relevant blood tests needed before the appointment, and if the patient could be seen by a GP with an extended role in rheumatology were recorded. The resultant rheumatological diagnosis from secondary care was recorded.
Results
Of 158 referrals, 86% were triaged to secondary care, the remainder were referred back to primary care or an alternative healthcare professional. Additional information from the EMIS record was added to 67% of all referrals and additional blood tests were requested in 26%. Of the 50 patients with outcome data, 40% were thought to have non-inflammatory conditions and could be seen in the community setting; this was confirmed in 85% after rheumatology assessment. The most frequent diagnosis in this group was fibromyalgia. Where an inflammatory condition was suspected by the referrer this was confirmed in 68%.
Conclusion
A significant number of referrals could be seen by a specialist GP in a community setting, the biggest single sub-set of these patients have chronic non-inflammatory pain. The provision of community GP-led rheumatology clinics could improve patient experience, reduce costs, and reduce the burden on secondary care.
Bethan Forgie, First Community Health Care
Email: bethangarrood{at}aol.com
Lisa Mallett, First Community Health Care
Helen Pritchard, First Community Health Care
Lauren Turner, East Surrey Clinical Commissioning Group
Opportunities and challenges of a novel cardiac output response to stress (CORS) test to enhance diagnosis of heart failure in primary care: a qualitative study
DOI: 10.3399/bjgp19X703421
Background
Primary care physicians lack access to an objective cardiac function test during diagnostic testing for suspected heart failure.
Aim
To determine the role of the novel Cardiac Output Response to Stress (CORS) test in the current diagnostic pathway for heart failure and the opportunities and challenges to potential implementation in primary care.
Method
Qualitative study using semi-structured in-depth interviews which were audiorecorded and transcribed verbatim. Data from the interviews were analysed thematically using an inductive approach. Fourteen healthcare professionals (six males, eight females) from primary (GPs, nurses, healthcare assistants, and practice managers) and secondary care (consultant cardiologists) participated.
Results
Four themes relating to opportunities and challenges surrounding the implementation of the new diagnostic technology were identified. These reflected that adoption of CORS test would be an advantage to primary care but the test had barriers to implementation which include establishment of clinical utility, suitability for immobile patients, and cost implication to GP practices.
Conclusion
The development of a simple non-invasive clinical test to accelerate the diagnosis of heart failure in primary care maybe helpful to reduce unnecessary referrals to secondary care. The CORS test has the potential to serve this purpose however, factors such as cost-effectiveness, diagnostic accuracy, and seamless implementation in primary care have to be fully explored.
Sarah Charman, Newcastle University, Medical School, Cardiovascular Research Centre
Nduka Okwose, Newcastle University, Medical School, Cardiovascular Research Centre
Gregory Maniatopoulos, Newcastle University, Institute of Health and Society
Sara Graziadio, Newcastle University, NIHR In Vitro Diagnostics Co-operative
Luke Vale, Newcastle University, Institute of Health and Society
Tamara Metzler, Newcastle University, Medical School, Cardiovascular Research Centre
Petar Seferovic, University of Belgrade, Medical School
Ahmet Fuat, Carmel Medical Practice, Darlington
Christi Deaton, Primary Care Unit, Institute of Public Health, University of Cambridge
Jonathan Mant, Primary Care Unit, Institute of Public Health, University of Cambridge
FD Richard Hobbs, University of Oxford, Nuffield Department of Primary Care Health Sciences
Djordje Jakovljevic, Newcastle University, Medical School, Cardiovascular Research Centre
Email: djordje.jakovljevic{at}newcastle.ac.uk
Is it safe to leave my patient at home? Interprofessional community-based learning
DOI: 10.3399/bjgp19X703433
Background
Joint training of clinicians working in overlapping care areas can be a powerful way to help develop cross-professional insights and knowledge, and stimulate shared reflection and development. This poster describes a novel educational evening, which saw GP trainees and South Central Ambulance Service (SCAS) staff coming together to learn and reflect through case-based discussion.
Aim
The aim of the educational evening was to enable participants to engage in shared learning activities using facilitated case scenarios based on common cases. Evaluation of the session highlighted in particular different approaches to risk management and uncertainty.
Method
Forty-seven (25 SCAS staff/22 GPs) participants attended the evening and worked in mixed SCAS/GP groups, which were facilitated by educators drawn from general practice and paramedic education. All participants completed pre-session information sheets and post-session evaluations.
Results
Participants valued the evening and reported broadened knowledge and insight about the clinical work of the other group, including the nature of work and differences in care management practice. Participants reported that the case-based scenarios were relevant.
Conclusion
The event helped participants to better understand each other’s roles gain and to learn together. The educational evening demonstrated that shared leaning can be powerful and generate insights for trainees and SCAS clinicians. Participants also made suggestions as to how the event might be developed for the future.
Heidi Penrose, Mid-Wessex GP Education
Email: heidi.penrose{at}winchester.ac.uk
Mark Ainsworth-Smith, South Central Ambulance Service NHS Foundation Trust
Carmel Wills, Mid-Wessex GP Education
Samantha Scallan, Southampton GP Education Unit
Evaluating health and well-being outcomes following the South Gloucestershire Pain Review pilot for patients on long-term opioids for chronic non-cancer pain
DOI: 10.3399/bjgp19X703445
Background
The South Gloucestershire Pain Review pilot is an individually-tailored service to help primary care patients on long-term (>3 months) treatment with opioid painkillers for chronic non-cancer pain understand their relationship with opioids and support alternative non-drug-based pain management strategies. The pilot was based in two GP practices in South Gloucestershire.
Aim
To evaluate the health and well-being outcomes and perceived impact of the pilot service to inform future service development.
Method
Quantitative data were collected for all enrolled patients on demographics; opioid use, misuse and dose; and pre-post intervention changes in health, well-being, quality of life (QoL), pain intensity/relief, and interference with life measures. Twenty-five semi-structured interviews (18 service users, seven service providers) explored experiences of the pilot including perceived impacts.
Results
Fifty-nine patients were invited to use the service and 34 (58%) enrolled. The median prescribed opioid dose reduced from 90 mg (interquartile range [IQR] 60–240) at baseline to 72 mg (IQR 30–160) at follow-up (P<0.001). On average, service users showed improvement on all health, well-being, and QoL outcomes except pain relief. The service was received positively. Perceived benefits related to well-being and QoL, use of pain management strategies (for example pacing), changes in medication use and changes in primary care use.
Conclusion
The pilot has shown promising results. The service was viewed as acceptable and health and well-being outcomes suggest a benefit. Following further development of the service, a randomised controlled trial is needed to formally test the effects of this type of care pathway on pain management and reducing long-term opioid use.
Jo Kesten, NIHR CLAHRC West / University of Bristol
Email: jo.kesten{at}bristol.ac.uk
Lauren Scott, NIHR CLAHRC West / University of Bristol
Kevin Bache, Developing Health & Independence
Rosie Closs, South Gloucestershire Council
Sabi Redwood, NIHR CLAHRC West / University of Bristol
Kyla Thomas, Population Health Sciences, Bristol Medical School, University of Bristol
Understanding the learning needs of London-based GP trainees in conducting telephone consultations
DOI: 10.3399/bjgp19X703457
Background
Telehealth care and telephone consultations are increasingly used in primary care for daily triage, patient reviews, and providing clinical information; however little is known about the perceptions of GP trainees.
Aim
To investigate the knowledge and skills of GP trainees in conducting telephone consultations; evaluate their current experiences and learning needs; and identify future training considerations based on feedback received.
Method
Using a mixed-methods approach, a cross-sectional quantitative survey of North Central and East London (NCEL) GP trainees was initially performed. This was followed-up by qualitative semi-structured interviews, which allowed deeper exploration of themes.
Results
In total 100 trainees responded to the survey, and eight proceeded with interviews. Trainees were least confident in independently undertaking more complex aspects of telephone consulting, and there was a positive correlation between training received and confidence to work independently. Despite positive and negative experiences, trainees felt that there were gaps in their training and significant differences in overall confidence, supervision and feedback among different training grades and between in-hours and out-of-hours practice. Future considerations included curricular promotion, increased trainer-trainee observations using audio-clinical observation tools or simulated practice, and consideration of formal training.
Conclusion
This project has shed light on the current learning, feedback, and assessment practices of GP trainees in conducting telephone consultations. Further evaluation will provide a helpful guide to various stakeholders, foresee any challenges and inform a wider debate among postgraduate learners regarding their training for the use of technology in healthcare.
Umar Chaudhry, Population Health Research Institute, St George’s University of London
Email: umar.chaudhry07{at}gmail.com
Judith Ibison, Institute of Medical and Biomedical Education, St George’s University of London
Tess Harris, Population Health Research Institute, St George’s University of London
Imran Rafi, Institute of Medical and Biomedical Education, St George’s University of London
Miles Johnston, Parliament Hill Medical Centre
Tim Fawns, Centre for Medical Education, The University of Edinburgh
An investigation into the early career intentions and training experiences of newly qualified GPs
DOI: 10.3399/bjgp19X703469
Background
Many UK areas are experiencing a shortage of GPs. Shortages present issues both for patients, who may not be able to get timely access to care, and GPs who may struggle to deliver high quality care when time is limited. Although several studies have shown how many new doctors intend to train as GPs, little is known about their career intentions as they complete training.
Aim
To gather cross-sectional evidence on how well prepared and motivated new GPs feel on completion of GP specialty training. Collect data about specific aspects of training, perceptions of GP work and what determines career planning and therefore their availability in the future GP workforce.
Method
An online questionnaire emailed to GPs within 1-year post certificate of completion of training. Recruitment via RCGP email and further publicity via social media.
Results
Although data collection is ongoing anticipated findings include indications of how responders could be better prepared for their roles and data on their level of commitment to substantive GP work and how they perceive future work (GP or other).
Conclusion
Sustained recruitment and retention of GPs is central for building a sustainable future GP workforce. Findings from this study will add information about what influences GP career intentions. In the context of shifting policies, practices, and expectations, these data are essential underpinnings for GP training and workforce planning.
Jon Gibson, University of Manchester
Email: jon.m.gibson{at}manchester.ac.uk
Sharon Spooner, University of Manchester
Kamila Hawthorne, RCGP
Lisa Johnsen, RCGP
Matt Sutton, University of Manchester
Evaluating reflection in postgraduate GP training post Bawa-Garba: a qualitative approach
DOI: 10.3399/bjgp19X703481
Background
It has been suggested that reflection within healthcare training bears little resemblance to theoretical approaches to reflective practice described in academia. Concerns have been raised about students producing artificial entries rather than an honest review of incidents encountered. The Bawa-Garba case is anticipated to have had a significant impact on the reflective practice of postgraduate medical trainees.
Aim
To evaluate the use of reflective learning logs in postgraduate general practice training in the context of the recent Bawa-Garba case.
Method
Using constructivist theory, a phenomenological approach to qualitative research was applied. During February to June 2018, 11 participants were recruited — seven trainees and four trainers — from the Doncaster GP Training scheme. Semi-structured interviews were performed and the data collected was transcribed for thematic analysis as described by Attride Sterling.
Results
Difficulty and challenge were identified as common themes for reflective log entries. There is support for previous findings regarding artifice, which commonly occurred in the context of evidencing curriculum coverage. All trainees expressed anxiety about the confidentiality of their reflective entries, with many describing a defensive approach to reflection following the Bawa-Garba case. International medical graduates (IMGs) were identified as being at a significant disadvantage in the current training scheme due to difficulties with language, cultural barriers, and previous experience of reflection.
Conclusion
A global theme identified from the data was that reflection within GP training needs to change in order to remove bias and prevent further devaluation of reflective learning.
Laura Emery, Health Education Yorkshire and the Humber
Email: laura.emery2{at}nhs.net
Shared care pitfalls: high dose antipsychotic monitoring in the community
DOI: 10.3399/bjgp19X703493
Background
Shared care is an integral part of monitoring patients on high-dose antipsychotics (HDA). These off-label prescription medications used for treatment resistant schizophrenia carry significant risk of harm, including sudden death. The challenges of monitoring HDA prescriptions are complex in the community setting.
Aim
Identify pitfalls in community HDA prescribing and monitoring through an audit of a busy London adult psychosis service caseload.
Method
Two years on from an initial caseload audit and multidisciplinary team education programme, compliance on HDA monitoring forms was re-audited in greater depth. Correspondence between the community psychiatric team and each patient’s GP was reviewed, looking for evidence of shared care protocols. Results were combined with a literature search.
Results
None of monitoring tests were adequately recorded. In 100% of cases windows for repeat ECG and observation monitoring had been missed. In 100% of cases blood tests had been carried out by the GP but this information was not documented appropriately. 0% of case records showed clear documentation of the shared care protocol from psychiatric team to GP.
Conclusion
HDA psychotic monitoring policies has been poor when audited at inpatient centres, however, these audits have led to improvements in guideline compliance. In this case, MDT education failed to lead to improvement. The primary–secondary care interface leaves GPs lacking certainty in their roles monitoring HDAs. Patients in the community are not always stable enough to have the insight or motivation to consistently engage with services. New strategies with a focus on shared care have been implemented to drive quality improvement.
Lara Shemtob, Royal Free Hospital
Email: lara.shemtob{at}nhs.net
Brian Douglas, Barnet Enfield Haringey Mental Health Trust
What are the opportunities for cancer care and related research in primary care? A qualitative study of the views of patients, carers, and practice staff
DOI: 10.3399/bjgp19X703505
Background
Research to identify the role of primary care in cancer care is important. However, trials in primary care are difficult.
Aim
To understand how patients, families, and primary care clinicians view their role in cancer care and identify opportunities for cancer primary care research.
Method
Qualitative study embedded within a feasibility cluster randomised controlled trial of a primary care based needs assessment intervention. The Supportive Cancer Needs Survey (SCNS) was the main outcome. In-depth interviews with patients/carers and focus groups with primary care staff explored views on cancer care and trial participation. Data were recorded, transcribed verbatim, and analysed thematically by three independent researchers.
Results
Fifteen cancer patients and three carers were interviewed and four focus groups (n = 11
) were conducted. Three themes were generated satisfaction with current care; key time-points for improved cancer care; and information and research. Satisfaction with current care among patients was high in spite of 72% reporting at least one moderate-high unmet need at baseline. Most patients undergoing cancer treatment were unsure when to access primary care. Patients and carers highly valued proactive contact from their practice following diagnosis though this was uncommon. Post-oncology discharge was a key time-point for information needs and support for patients. Patients were reluctant to consider palliative care in spite of palliative care needs. Some felt therapeutic benefit from completing study measures.
Conclusion
Patients are satisfied with cancer primary care despite unmet needs. Palliative care is poorly understood by many who may benefit. Research participation may benefit some patients.
Joseph Clark, Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull
Email: joseph.clark{at}hyms.ac.uk
Elvis Amoakwa, Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull
John Blenkinsopp, University of Northumbria
Florence Reedy, University of Hull
Miriam Johnson, Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull
Evaluating the impact of ‘Be Clear on Cancer’ awareness campaigns on GP attendances
DOI: 10.3399/bjgp19X703517
Background
The ‘Be Clear on Cancer’ awareness campaigns aim to raise awareness of cancer symptoms and encourage people with these symptoms to ‘tell their doctor’. GP attendances are therefore a key metric for evaluating the impact of a campaign. We considered the impact on GP attendances of several campaigns since 2013, including the 2015 national oesophagogastric cancer campaign, the 2016 national respiratory symptoms campaign and campaigns for lung cancer, ‘blood in pee’, and breast cancer in women aged >70 years.
Aim
To consider the impact on GP attendances of several campaigns since 2013, including the 2015 national oesophagogastric cancer campaign, the 2016 national respiratory symptoms campaign and others.
Method
Data on the weekly numbers of GP attendances and practices were extracted from The Health Improvement Network (THIN) database. For patients reporting campaign symptoms or a control symptom (back pain), the average number of GP attendances per practice per week was calculated. Analysis considered the trend in GP attendances, calculated the change in attendances for the campaign period compared to the same period in an earlier year, and assessed this change using a χ2 test.
Results
The 2015 oesophagogastric cancer campaign, resulted in a statistically significant 29% increase (P<0.001) in the number of attendances for symptoms of dyspepsia and dysphagia, compared with the same period in 2013. Conversely, there was no significant change in attendances for back pain. Results for other campaigns will be presented.
Conclusion
The THIN database has provided primary care data which can be used to assess the impact of awareness campaigns on primary care activity. Results demonstrate increases in GP attendances following some of the campaigns, suggesting that some patients responded to the campaigns’ call to action.
Christopher Lawrence, Public Health England
Carolynn Gildea, Public Health England
Ann Watters, Public Health England
Isobel Tudge, Public Health England
Email: isobel.tudge{at}phe.gov.uk
Evaluating a large-scale roll out of blood pressure telemonitoring using routinely acquired data
DOI: 10.3399/bjgp19X703529
Background
1.2 million appointments in Scottish primary care annually are used solely for checking blood pressure (BP). While evidence from randomised controlled trials (RCTs) shows that telemonitoring of BP produces significant reductions, it has not been mainstreamed because of difficulties in integrating telemonitoring with routine medical care. With NHS Lothian a system was developed which extracted data from a telemonitoring provider website, and delivered it as a routine DOCMAN report to GP practices without need for logons.
Aim
To determine the feasibility of implementing telemonitoring of high blood pressure (HBP) at scale in primary care and the potential of using routinely acquired data for exploring clinical and resource-use impacts.
Method
Practice recorded BP, prescribing, and appointments data were transferred for all people with HBP to a safe-haven. We compared before and after BPs at 1 year from participants and non-participants. Patient and clinician interviews.
Results
Over 2400 people were recruited to telemonitoring overall. Over a year, BP control improved in both telemonitoring participants and non-participants. Mean systolic BP (SBP) fell by 6.6 mmHg in participants and 3.5 mmHg in non-participants. In uncontrolled participants (SBP >135 mmHg home-monitored) average fall was 15 mmHg. Proportion with very poor control BP (SBP >150 mmHg) fell from 13.6% to 3.4%. Appointment data were challenging to interpret, but there was little change from the previous year in face-to-face appointment time and total appointments. Patients and clinicians were positive about the implementation
Conclusion
The study demonstrated an improvement in BP control similar to effects in RCTs in routine general practice with little impact on workload using routinely acquired data providing strong support for mainstreaming low-cost telemonitoring for HBP.
Brian McKinstry, University of Edinburgh
Email: brian.mckinstry{at}ed.ac.uk
Vicky Hammersley, University of Edinburgh
Richard Parker, University of Edinburgh
Hilary Pinnock, University of Edinburgh
Paul Padfield, University of Edinburgh
Janet Hanley, Edinburgh Napier University
Andrew Stoddart, University of Edinburgh
Adam Steventon, Health Foundation
Innovating to build GP trainer capacity in London
DOI: 10.3399/bjgp19X703541
Background
A new GP trainer programme was developed by Health Education England (HEE) London in recognition of the need to expand GP trainer capacity across London, providing a flexible, non-accredited course within existing resources. An evaluation of its effectiveness was commissioned to assist the future development of primary care training courses.
Aim
The aim of the new GP trainer programme was to provide GP educators with access to authentic, practical, ‘real world’ experiences of GP training. It was also to build and connect the GP community; in particular, the GP training community. Indeed, the course aimed not only to encourage GPs to become trainers but in a very real sense ensure their preparation for practice.
Method
The programme consisted of five compulsory face-to-face taught days; self-directed learning via online modules, podcasts and reading; compulsory attendance at local GP trainer workshops; and an optional reflective portfolio.
Results
The rationale behind the development of the programme was that the appropriate education of primary healthcare practitioners is dependent on trainers having a sound understanding of key adult learning principles as well as the necessary practical and professional skills to facilitate effective teaching, learning, and assessment in practice. It purposefully lowered barriers to participation by emphasising and focusing on the practical application of relevant educational theory, and ensuring that assessments of GP trainer’s competence are appropriate and proportionate.
Conclusion
This presentation will discuss the processes and decisions involved in developing and designing this programme, as well as the implications of a recent evaluation of its impact.
Andrew Tate, Health Education England
Email: andrew.tate{at}hee.nhs.uk
Nerys Carter, Health Education England
Sarah Osborne, Health Education England
Identifying and rectifying prescriptions of long-acting antimuscarinic and beta-agonist inhalers without inhaled corticosteroids to asthma patients: an audit from a UK general practice surgery
DOI: 10.3399/bjgp19X703553
Background
In the UK 5.4 million people receive treatment for asthma. Patients diagnosed with asthma should not be prescribed a long-acting muscarinic antagonist (LAMA), or a long-acting beta 2 agonist (LABA) without co-prescription of an inhaled corticosteroid (ICS), due to the increased risk of death.
Aim
To identify patients with asthma (+/− COPD), who have a current prescription for a LABA/LAMA without an ICS.
Method
Audit criteria were derived from guidelines relevant to the Asthma UK national review, with standards of 100%. An electronic medical record search identified patients prescribed a LABA/LAMA without an ICS. Patients without a coded diagnosis and those with a diagnosis of asthma (+/− COPD) were identified for action.
Results
Fifty-four patients from the practice population (n = 11 293) were prescribed a LABA/LAMA without an ICS. Of these, 7% (n = 4) did not have a relevant coded diagnosis. Of the remaining 50 patients, 16% (n = 8) had a diagnosis of asthma (+/− COPD). Re-audit results found 3% (n = 2) of patients did not have a relevant coded diagnosis. Patients with an asthma (+/− COPD) diagnosis on a LABA/LAMA without an ICS decreased to 11% (n = 7).
Conclusion
Suboptimal coding and potentially risky prescriptions were identified. Interventions were to ensure patients have a coded diagnosis, review LABA/LAMA without ICS prescriptions, discuss audit results with practice prescribers, and to activate electronic alerts to prompt safe prescriptions. Following re-audit, the patients with asthma (+/− COPD) still on a LABA/LAMA have been offered appointments to clarify their asthma diagnosis or to explain the risks associated with LABA/LAMA prescription without an ICS.
Toni Robinson, Keele University
Email: tonimiller{at}hotmail.co.uk
John Edwards, Wolstanton Medical Centre
Elizabeth Cottrell, Wolstanton Medical Centre
The combined care clinic: a strategy in improving quality and efficiency related to essential patient reviews in the UK
DOI: 10.3399/bjgp19X703565
Background
Standardised delivery of patient care remains an essential facet of the NHS. In 2004, the general practice contract for delivering specific primary medical services incorporated a financial payment: Quality Outcomes Framework (QOF). In majority of practices, these reviews are completed by the practice nursing healthcare team.
Aim
To understand if the combined care (CC) clinic improves the efficiency in delivering patient reviews.
Method
The CC clinic was designed in 2015 inviting patients with diabetes; who may also have other long-term conditions, to be addressed in a ‘one stop’ approach. It is implemented by healthcare assistants (HCAs) supported by apprentices, who perform standard checks such as blood pressures, urine dipstick checks, smoking data, and health promotion that are protocolled. Where there are abnormalities noted, the HCA is able to escalate to the practice nurses who are supported by a GP lead.
Results
QOF diabetes data were reviewed from 2015–2016 (636 patients on register) and 2016–2017 (649 patients on register). Results showed a marked percentage increase between years in the following indicators: DM003 (last blood pressure measurement ≤140/80 mmHg) 7.29%; DM006 (proteinuria/microalbuminuria) 6.20%; and DM009 (foot exam) 3.21%. All other diabetic indicators apart from two showed a percentage increase. The proportion of patients seen between April–October also increased in the subsequent year.
Conclusion
The CC clinic provides a method of patient review in an efficient process, without the need for multiple visits, thereby increasing practice capacity to focus on other aspects of patient care and work streams.
Nishaan Khoosal, Jubilee Medical Practice
David Swanson, Jubilee Medical Practice
Girish Purohit, Jubilee Medical Practice
Cath Morgan, Jubilee Medical Practice
Amit Bharkhada, Jubilee Medical Practice
Email: amitbharkhada{at}hotmail.com
A systematic review of routine HIV testing in primary care
DOI: 10.3399/bjgp19X703577
Background
This study aims to contribute to the improvement of European progress towards 90–90–90 targets and to identify an intervention with a strong evidence base used in better performing countries such as routine testing in primary care.
Aim
To evaluate the efficacy of routine HIV testing in primary care and identify the barriers and solutions towards successfully implementation.
Method
Peer-reviewed studies which measure changes in provider offer rates, patient uptake rates, seroprevalence or CD4 counts after the implementation of routine HIV testing. Studies which identified barriers and solution to implementation were also included. EMBASE and MEDLINE were searched through April 2018. Risk of bias was assessed using the CASP framework, regarding participant selection, randomisation incomplete outcome data, blinding, and use of sensitivity analyses.
Results
Routine HIV testing shows increased rates of case finding with earlier diagnosis when compared to standard practice. Factors such as sex, ethnicity, local prevalence, and stigma were found to affect patient uptake, while gaps in training, awareness and organisational implementation affected provider uptake. Provider offer rates require adequate education regarding intervention efficacy, electronic medical record use, and result communication. Addressing time constraints with nurse-initiated testing and combined condition testing can improve the clinical workflow. Normalising HIV testing, including reforming pre-test counselling, rapid testing, and education to reduce stigma can improve patient uptake. Further analysis of cost-effectiveness is also required to effectively consider implementation.
Conclusion
Routine HIV testing across primary care can improve testing rates, with consideration to barriers towards implementation and further study.
Amandeep Pahal, St George’s, University of London
Email: amandeepkp1996{at}gmail.com
Anjelli Wignakumar, Imperial College London
Riddhi Shenoy, Imperial College London
Ragul Ravimohan, Imperial College London
Harmanjit Singh, Imperial College London
Ben Subani, University of Brighton
Sirtaaj Mattoo, Imperial College London
Vasectomy: can the standards be achieved within a primary care setting?
DOI: 10.3399/bjgp19X703589
Background
Vasectomy intends to provide permanent contraception by interrupting the vas deferentia via one of several methods. The no-scalpel vasectomy aims to render male sterilisation more acceptable to patients. It is faster and associated with fewer complications. Complications are uncommon, but do exist, most often pain, bleeding, bruising, and infection. Vasectomy is increasingly carried out within a primary care setting. One GP at Marple Cottage Surgery has been performing vasectomies for 5 years.
Aim
This study aims to ascertain whether vasectomy standards can be achieved within a primary care setting.
Method
Electronic patient records and semen analysis data were accessed for procedures performed between April 2013–April 2018, to calculate the failure and complication rates. This was compared to guidelines from relevant advisory bodies.
Results
In total 910 vasectomies were performed over the period: 5.3% were associated with a complication; 2.0% intraoperative bleeding, 1.5% pain, 0.8% haematoma, 0.7% syncope, and 0.2% infection. Two-thirds (67.3%) of patients provided a semen sample for analysis. The occlusive failure rate was 0.4% and the contraceptive failure rate is 0%.
Conclusion
Complication rates were low, achieving or exceeding the standards in all domains. The occlusive failure rate is within the <1% American Urological Association acceptable standard and the current contraceptive failure rate is 0%. This is for further analysis with a larger sample size. We are confident that the high standard of vasectomy care can be achieved as the service migrates into primary care.
Caitlin Gorman, NHS East Cheshire
Email: caitlingorman{at}nhs.net
Francis Hunt, NHS East Cheshire
Maher Al-Ausi, Marple Cottage Surgery
The CHARIOT Register: a primary care-based recruitment register for research into dementia and healthy ageing
DOI: 10.3399/bjgp19X703601
Background
The Cognitive Health in Ageing Register: Investigational, Observational and Trial studies (CHARIOT) is a primary care-based register for research studies involving the prevention of dementia and other age-related diseases. The Register was developed in 2012 in collaboration between London GP surgeries and researchers at the School of Public Health at Imperial College London. It was designed to offer opportunities for volunteers to participate in research studies.
Aim
The aim is to build a register of individuals aged 50–85 years who are cognitively intact and are willing to be contacted about research studies on dementia prevention and healthy ageing.
Method
Potential participants are recruited through London-based GP surgeries. On consenting to join the register, basic demographic and contact details are then extracted from their GP surgery and securely uploaded to the Imperial College database. Based on the data collected, Register members are then approached to participate in new research studies.
Results
To date, 164 GP surgeries have collaborated to invite over 170 000 individuals to join the CHARIOT Register, resulting in the recruitment of 33 911 participants. From those who have joined the Register, 8419 have consented to take part in ageing-related studies, giving a response rate of 24%.
Conclusion
The CHARIOT Register facilitates research for the prevention of dementia and ageing-related diseases. It has been shown that this approach to easily access and recruit keen participants onto research studies has been effective, allowing for the development of new strategies to grow the Register.
Hiba Wanis, Imperial College London
Email: h.wanis{at}imperial.ac.uk
Exploring the educational value of an ITP in integrated community care
DOI: 10.3399/bjgp19X703613
Background
ITPs (Integrated or Innovative Training Programmes) have been recognised as a distinct type of training post for general practice. Previous research has found them to provide an enhanced training experience. This work describes and evaluates a ‘new generation’ ITP post which piloted in the New Forest.
Aim
The evaluation aimed to determine if the integrated structure provided a positive educational experience and if it prepared trainees for a career in general practice. It was designed and conducted by GPST3 trainees.
Method
The post comprised a mix of 2 days a week in GP and 3 days in community healthcare posts. The posts were evaluated using a focus group of trainees and trainers, and a survey.
Results
Participating trainees and trainers reported that the post was helpful in developing skills and competencies related to community care, but identified some challenges. Three key themes were identified: perceptions of improved quality of training; feeling better prepared for a career in GP; and better awareness of primary–secondary care system and interface.
Conclusion
ICCs mark a welcome return of ITPs to GP training and can offer a positive experience to trainees in developing their care knowledge and skills. The trainees undertaking this evaluation gained insight into evaluation research. There continues to be a role for integrated training posts in training, especially with the increasing care complexity. ITPs can add a different dimension to experience in training.
Laura Sheldrake, Southampton GP Education Unit
Email: laura.sheldrake{at}hotmail.com
Johnny Lyon-Maris, Health Education England (Wessex)
Samantha Scallan, Southampton GP Education Unit
Test Talk: an observational study exploring the discussion of blood tests in routine primary care consultations
DOI: 10.3399/bjgp19X703625
Background
Clinicians are encouraged to share decisions about treatment options with their patients, however to-date there has been little research attention focusing on the discussion of investigations.
Aim
This study explored shared decision making (SDM) regarding blood testing during routine primary care consultations.
Method
This observational study used inductive and deductive qualitative content analysis to examine 50 consultations. Data were sampled from the One in a Million archive, which contains video-recordings of 300 primary care consultations and linked data between GPs and adult patients with permissions for reuse. The discussion surrounding both ordering blood tests and conveying results was coded, including who instigated testing, whether there was SDM, and how results were explained to patients.
Results
During 36/50 consultations in which ordering blood tests was discussed, 31% of patients hinted they wanted a blood test, however none explicitly asked: 32% of patients were informed about all blood tests ordered. Only 11% were offered any alternative options. In 81% of cases the GP gave some explanation of why the test was indicated, but only 17% explained any limitations of testing. Of 23/50 consultations in which results were conveyed, the GP gave no explanation of the results in 26% of cases: 57% of patients were only informed of an ’assessment’ of the result, not the actual result.
Conclusion
This study identifies numerous areas for improvement in terms of patient information and SDM surrounding blood testing. Promoting SDM has been hypothesised to reduce rates of unnecessary testing and could potentially improve patient-centred care and efficiency.
Jessica Martin, University of Bristol
Email: jessica.martin{at}doctors.org.uk
Jessica Watson, NIHR CLAHRC West / University of Bristol
Rebecca Barnes, Population Health Sciences, University of Bristol
Perceptions and experiences of rare diseases among the GP population in Northern Ireland
DOI: 10.3399/bjgp19X703637
Background
Rare diseases are often complex, life-long conditions with a genetic basis. With advances in phenotyping and genomic medicine, there are now >8000 rare diseases reported. A rare disease is defined by an incidence of <5 cases per 10 000 population; although they are individually rare, collectively they are much more common with 1 in 17 persons affected in their lifetime. The Northern Ireland Rare Disease Implementation Plan (2015) highlighted the need for better coordination of care, the empowerment of patients, better diagnostics, and earlier disease interventions. The report also acknowledged the difficult role that GPs have, especially in the diagnosis of rare diseases. GPs play an important role in healthcare delivery for people living with a rare disease and their families. However, many GPs report challenge identifying and managing individuals with a rare disease appropriately.
Aim
To explore GP’s perceptions and experiences of rare diseases.
Method
A literature review of published research related to GPs and rare disease will be conducted. Databases searched include Medline, Embase, Web of Science, Scopus and Google Scholar. Additionally, an online survey will be completed by GPs November 2018–spring 2019, with follow-up qualitative interviews providing further in-depth information.
Results
Initial searches have revealed 27 relevant publications. A summary of the findings from the literature review will be presented, alongside findings from our GP survey.
Conclusion
Much can be learned from the experiences of current GPs to identify rare disease information needs and resources that enable effective GP-patient partnerships.
Julie McMullan, Queen’s University Belfast
Taylor McC lenaghan, Queen’s University Belfast
Ashleen Crowe, Queen’s University Belfast
Amy Jayne McKnight, Queen’s University Belfast
Helen McAneney, Queen’s University Belfast
Email: h.mcaneney{at}qub.ac.uk
Exploring student perceptions and awareness of social prescribing
DOI: 10.3399/bjgp19X703649
Background
The importance of social prescribing has been illustrated by the NHS Long Term Plan, as well as the GP Forward View published in 2016. Social prescribing is enabling healthcare professionals to refer patients to a link worker, to co-design a non-clinical social prescription to improve their health and well-being. A lack of awareness of social prescribing has been suggested in the past, although no studies have been formally conducted to date to provide the evidence basis for this statement.
Aim
Exploring perceptions, understanding, and awareness of social prescribing among medical students across the UK.
Method
Student views were collected using a survey delivered before and after teaching sessions as part of the NHS England National Social Prescribing Student Champion Scheme. A total of 932 responses were recorded from 27 different medical schools.
Results
Pre-session surveys suggested that 91% (n = 848
) of medical students have never heard of the concept of social prescribing before the teaching session. Post-session surveys highlighted that 98% (n = 913
) of students regarded the concept as useful and relevant to their future careers following teaching on the subject.
Conclusion
Survey findings confirm a significant lack of awareness regarding social prescribing among medical students from 27 different medical schools across the UK. New strategies are needed to ensure the doctors of tomorrow are equipped with the necessary tools to achieve the recent outcomes for graduates which highlight the importance of personalised care and social sciences.
Hannah Mulligan, University of Exeter Medical School
Email: hlam201{at}exeter.ac.uk
Daisy Kirtley, University of Exeter Medical School
Claudia Santoni, University of Cambridge
Joel Chilaka, Brighton and Sussex Medical School
Bogdan Chiva Giurca, University of Exeter Medical School
Association of mortality and warmer weather below heatwave thresholds, in Berlin, Germany, between 2013 and 2015: a retrospective study
DOI: 10.3399/bjgp19X703661
Background
While an association between increased mortality and heatwaves is well known, less is known about higher temperatures ranges below heatwaves and mortality, in urban settings.
Aim
To establish if there was an association between mortality rates within the population of Berlin, during defined risk periods of daily warmer temperatures between 2013 and 2015.
Method
A retrospective secondary data analysis of death counts, population, and temperature data from Berlin. A defined risk periods model of specified temperature ranges of daily minimum and daily maximum temperatures investigated May to September, from 2013 to 2015. A Poisson regression model established incidence rate ratios (IRRs) for mortality. Effect size was estimated in ‘lives lost’.
Results
Mortality rates were noticeably increased during defined risk periods for all people aged ≥65 years during daily temperatures of ≥18 to ≤29°C. In people aged ≥75–84 years, during risk period ≥18°C to ≤29°C, incidence risk ratio (IRR) was 1.22 (95% confidence interval [CI] = 1.07 to 1.40, P = 0.004
). For females aged 65–74 years, during ≥18°C to ≤29°C, a higher mortality rate was found, compared to males (females: IRR 1.28, 95% CI = 1.15 to 1.42, P<0.001; males: IRR 0.93, 95% CI = 0.78 to 1.10, P = 0.390
). Effect size calculation estimated an additional 252 deaths in Berlin, between 2013 and 2015, with 133 deaths in the ≥85-year group.
Conclusion
As mortality of older people increased during defined warmer weather, temperatures below heatwave ranges need acknowledgement as a risk factor for health. Policies and health warning systems should include daily minimum temperatures.
Heinz Tilenius, University of Glasgow
Email: heinz.tilenius{at}nhs.net
eHub: Enhancing the emergence of the electronic consultation
DOI: 10.3399/bjgp19X703673
Background
Alternatives to face-to-face consulting (F2F) with patients have been developed including telephone consulting and e-consulting. One area of concern about both alternatives is that they may act to increase total consultation time by generating additional F2F consultation activity.
Aim
To determine the proportion of clinical e-consults where a GP requested a follow-up F2F consultation and to determine whether e-consultation training reduced the proportion of GP requests for a follow-up F2F consultation.
Method
A longitudinal study was conducted observing ‘remote closure’ rates (the proportion of clinical e-consults with no F2F follow-up appointment) before and after the launch of a dedicated at scale electronic consultation ‘eHub’ with a bespoke technical and clinical training programme. Remote closure rates were available for 42 months prior and 22 months following the intervention. A follow-up GP consultation was defined as the doctor requesting the patient to make a F2F appointment.
Results
The remote closure rates were 63% (3019/4778) before and 87% (6957/7993) after the intervention. χ2 with Yates correction 1024.9; P<0.001.
Conclusion
The consultation as a core competency of GP training requires specific skills for e-consulting. We have devised a training package for e-consultation training. Following implementation of a package of intensive e-consultation training, remote closure rates of 87% were obtained. Some of the observed increase in remote closure rates may have been attributable to increased familiarity of both GPs and patients with new models of consultation. We plan to test our e-consulting educational package in other settings with low e-consultation closure rates.
Ross Dyer-Smith, Hurley Group
Email: ross.dyer-smith{at}nhs.net
Gurbaksh Badial, Hurley Group
Does applicant specialty ambition influence medical school choice?
DOI: 10.3399/bjgp19X703685
Background
The NHS is critically short of doctors. The sustainability of the UK medical workforce depends on medical schools producing more future GPs who are able and willing to care for under-served patient populations. The evidence for how medical schools should achieve this is scarce. We know medical schools vary in how they attract, select, and educate future doctors. We know some medical schools produce more GPs, but it is uncertain whether those school recruit more students who are interested in general practice.
Aim
This study seeks to explore how applicants’ future speciality ambitions influence their choice of medical school.
Method
One-to-one semi-structured interviews and focus groups were conducted with medical applicants and first year medical students at eight medical schools around the UK. Interviews were audiorecorded and transcribed verbatim. Transcripts were analysed through thematic analysis by one researcher. A sample of 20% of transcripts were analysed by a second researcher.
Results
Sixty-six individuals participated in 61 individual interviews and one focus group. Interviews lasted a mean of 54 minutes (range 22–113). Twelve expressed interest in general practice, 40 favoured other specialities, and 14 were unsure. Participants’ priorities varied by speciality aspiration; those interested in general practice described favouring medical schools with early clinical experience and problem-based learning curricula, and were less concerned with cadaveric dissection and the prestige of the medical school.
Conclusion
Many applicants consider future speciality ambitions before applying to medical school. Speciality aspiration appears to influence priority of medical schools’ attributes.
Eliot Rees, University College London
Email: e.rees{at}ucl.ac.uk
David Harrison, University College London
Karen Mattick, University of Exeter Medical School
Katherine Woolf, University College London
The Royal College of General Practitioners (RCGP) quality improvement initiative using Clinical Practice Research Datalink (CPRD) data: Lessons learned
DOI: 10.3399/bjgp19X703697
Background
Quality improvement (QI) is a priority for general practice, and GPs are expected to participate and provide evidence of QI activity. Pressures on the primary care workforce require approaches to QI to prioritise efficiency and effectiveness.
Aim
This project aimed generate and scale up bespoke QI reports for GP practices contributing data to CPRD.
Method
CPRD is a UK government research service facilitating public health research using anonymised primary care data. A pilot report was designed with stakeholders and covered two indicators from the RCGP Patient Safety Toolkit. The reports enabled GPs to identify patients needing case review and to benchmark data on practice-level prescribing. Reports for 12 practices, containing real patient data, were sent to GPs and feedback was obtained via interviews. The report was scaled up to 457 practices and a survey sent out to request feedback.
Results
GPs used the reports to review the care of individual patients, and to implement QI actions such as adding flags to patients notes. One participant used the report as evidence for their annual appraisal. Survey response was limited (n = 31.7%
) but overwhelmingly positive. Responders highlighted the importance of clinical input when developing indicators and ensuring the tone of the reports is supportive.
Conclusion
The collaborative RCGP/CPRD QI reports are unique in their ability to provide benchmarking and case-finding on a national scale. The indicators selected must lead to actionable reports. Clinical input is required to ensure code lists are appropriate and that reports are clinically relevant. CPRD aims to send out two reports annually.
Helen Booth, Clinical Practice Research Datalink
Email: helen.booth{at}mhra.gov.uk
Eleanor Yelland, Clinical Practice Research Datalink
David Mullett, Royal College of General Practitioners
Arlene Gallagher, Clinical Practice Research Datalink
Shivani Padmanabhan, Clinical Practice Research Datalink
Stephen Welburn, Clinical Practice Research Datalink
Janet Valentine, Clinical Practice Research Datalink
Puja Myles, Clinical Practice Research Datalink
GP–consultant liaison Southampton 2018
DOI: 10.3399/bjgp19X703709
Background
Collaborative working across primary and secondary care is crucial to providing quality, safe care.
Aim
Improve professional understanding, foster deeper partnership, ignite opportunities for innovation and quality improvement (QI) with co-owned local solutions.
Method
Fifty-nine consultants and GPs were strategically paired to enhance working relationships. Pairs hosted and visited each other’s workplace. Anonymous reflections were analysed for common themes and celebrated in an evening of shared learning where the focus was on compassionate leadership and next steps.
Results
Feedback from 71 (60%) participants was scaled from 1 (least likely) to 6 (most likely). Individuals supported a regular primary–secondary care forum; weighted average score of 5.25, found the scheme useful (4.59), likely to take part again (4.83), consider new ways of working (3.85). Production of leaflets on psychological support for patients in hospital consequent to insight obtained from primary care were produced, directories of primary care secretary’s were shared and outpatient clinic letters to state ‘For Information Only’ or ‘GP Action Required’ were restructured resulting in substantial time and cost savings. The liaison improved morale and insight and built better relationships. Common themes from reflections revolved around compassion, collaboration, complexity, efficiency, and education.
Conclusion
This scheme was an easy and enjoyable way to reconnect individuals and allowed professionals to learn about challenges we face within the NHS. As QI activity, the scheme resulted in simple local solutions for patients. It is a low-cost intervention that can be replicated within any organisation in the NHS. It needs a motivated and persistent individual driving the project forward.
Pritti Aggarwal, Southampton City Clinical Commissioning Group; University of Southampton; Living Well Partnership, Southampton; Thames Valley Wessex Leadership Academy
Email: prittiaggarwal{at}nhs.net
Sally Ross, Portsmouth Clinical Commissioning Group; Thames Valley Wessex Leadership Academy
Adam Fraser, Medical Practice, Weymouth; Bournemouth University
- © British Journal of General Practice 2019
