GPs warn over scoring system for calling ambulances for patients

A scoring system designed to identify deteriorating patients in secondary care is “creeping” into primary care, despite a lack of evidence for its use in community settings, GPs have warned.

GPs are being asked to provide a score when calling for an ambulance for a patient and are concerned that this is being used to decide how urgently their patient needs an ambulance, over-riding their clinical judgment.

The issue was raised at the Royal College for General Practitioners’ council meeting on 20 September, where members voiced concern about the lack of evidence for using NEWS2, an updated version of the National Early Warning Score, in primary care.

The scoring system is used to identify and respond to patients at risk of deteriorating. It is based on six physiological measures: respiratory rate, oxygen saturation, temperature, systolic blood pressure, pulse rate, and level of consciousness.

Despite not being validated for community or primary care, NHS England has now “encouraged” the use of NEWS2 in these settings. In NHS England’s list of frequently asked questions on NEWS2, it argues that although there is “limited evidence,” the score “provides an objective assessment of a patient’s physiological state and adds to clinical judgement”1

Last year use of the scoring system was made mandatory in ambulance trusts.2 NHS England said they should use the score “for all pre-hospital patients who are ill or at risk of deteriorating” and to “support colleagues to identify deterioration early and prioritise resources in times of surge,” as part of a wider assessment.

Sam Finnikin, a GP and clinical research fellow at the University of Birmingham, said that though NEWS2 could be a “useful communication tool, there are risks that it will be used to guide clinical decision making as well.” He argued that the score did not always indicate need, as most patients admitted to hospital have a low score, while some patients with a raised score can be treated in the community.

Finnikin, who was present at the RCGP council discussion, said, “Already many GPs are having to provide a NEWS2 score before they get an ambulance sent for their patient. But we don’t know how this is being used. Does a 70 year old with a suspected myocardial infarction and a NEWS2 of 1 become a lower priority than a 26 year old with pyelonephritis and a NEWS2 of 5? Is this the right decision?”

He added, “The creeping use of NEWS2 into settings where it is not validated and its impact on patient outcomes has not been studied is irresponsible. Show me the evidence that using NEWS2 in primary care reduces deaths from sepsis without harming other patients and I will happily change my mind.”

After the meeting, RCGP council representative Margaret McCartney wrote in a blog post, “Physiological measures are one thing. NEWS scores to prioritise ambulances should not be used from primary care. NEWS was developed as a measure to transfer patients in hospital to high intensity care settings; we cannot assume that this will result in good care either through overdiagnosis and underdiagnosis, and we should not proceed without high quality evidence that it is safe.”3

An RCGP spokesperson said, “We passed recommendations to support the use of physiological measurement in a GP setting, and for more focused research on the use of NEWS2 scores in primary care—but council members voted against voluntary uptake [of NEWS2] as a common communication tool in general practice.”

NHS England told The BMJ that it had created a framework to standardise requests for ambulances made by healthcare professionals, including GPs, which was agreed with the BMA and RCGP.4 It said that although NEWS-2 may be used to support standardised communication and prioritisation, GPs can and should request a higher priority ambulance response on the basis of their clinical judgment and regardless of the NEWS-2 score, such as for patients with heart attack, stroke, acute abdominal pain, or severe bleeding.