Blog posts

Understanding the challenges for GPs in managing overweight & obese children

As part of a research project on the effectiveness of the NCMP (National Child Measurement Programme), a workshop was held in the School of Public Health to evaluate the current use of National Child Measurement Programme feedback by GPs. The aim was to investigate how GPs feel they could add further value to NCMP feedback in the future and any challenges they face incorporating National Child Measurement Programme feedback into their routine clinical work.

The workshop was facilitated by Dr Sonia Saxena & Prof Russell Viner, with participation from Dr Zoe Williams and Dr Rachel Pryke.

In the interactive 2-hour workshop, the audience discussed and came up with different ideas and solutions to overcome barriers faced in monitoring childhood obesity in Primary Care as well as the National Child Measurement Programme feedback. They specifically highlighted the importance of allocating more time for growth and weight checks, improving awareness of appropriate local weight management services and developing an integrated system with BMI centiles entered before consultations.

They also suggested introducing obesity/overweight topics into the CSA examination for GP trainees. Furthermore, attendees underlined the importance of educating GPs on a healthy lifestyle, weight management and specific approaches on how to address these sensitive topics in consultations with families effectively.

Workshop discussions provided a base to develop a short survey on how the National Child Measurement Programme link can better with primary care.

Are diagnoses of dementia being delayed by over-complex referral criteria?

Complex and time-consuming memory clinic referral criteria may be contributing to delays in the diagnosis of dementia, according to a paper published today by the Journal of the Royal Society of Medicine. Around 850,000 people are living with dementia in the UK but the number thought to have dementia substantially exceeds those with a formal diagnosis. Early diagnosis is a priority for the government and the NHS.

Currently GPs are responsible for referring patients for assessment and diagnosis by specialists, usually in dedicated memory clinics which set referral criteria. There is considerable variation in referral criteria, with requirements set by some memory clinics that exceed national guidelines. Requirements can include different combinations of cognitive tests, laboratory blood tests, urine tests and physical examination that vary between clinics.

Lead author Dr Benedict Hayhoe, of the School of Public Health at Imperial College London, says: “GPs have difficulty assessing patients with memory problems in strict accordance with guidance within a 10-minute consultation; in our experience a significant proportion of available consultation time can be taken up by carrying out just one of the brief cognitive tests.” He went on to suggest that, with current workload pressures on primary care, complex criteria involving multiple investigations are likely to provide a significant disincentive for referral.

The authors set out alternative approaches to speed up diagnosis. Dr Hayhoe said: “A primary care led process, perhaps staffed by practice nurses carrying out assessments according to protocols, may speed up diagnosis while reducing pressure on GPs and specialists.” He added that it may also be appropriate to allow some people with memory concerns direct access to memory clinics.

Dr Hayhoe concludes: “A system that discourages or delays referral for dementia is highly counterproductive; an urgent review of this area is necessary to establish a system that effectively supports patients and clinicians in early diagnosis, treatment and prevention“.

The article was reported by a number of media outlets including: The Times, The Express, The Alzheimer’s Society, Pulse and the Jersey Evening Post. The article was also reported by World First, homecare.co.uk, Care Appointments, and the Hippocratic Post.

Preventing delayed diagnosis of cancer: clinicians’ views on main problems and solutions

Delayed diagnosis is a major contributing factor to the UK’s lower cancer survival compared to many European countries. In the UK, there is a significant national variation in early cancer diagnosis. Healthcare providers can offer an insight into local priorities for timely cancer diagnosis. In a study published in the Journal of Global Health, we aimed to identify the main problems and solutions relating to delay cancer diagnosis according to cancer care clinicians.

We developed and implemented a new priority–setting approach called PRIORITIZE and invited North West London cancer care clinicians to identify and prioritize main causes for and solutions to delayed diagnosis of cancer care. Clinicians identified a number of concrete problems and solutions relating to delayed diagnosis of cancer. Raising public awareness, patient education as well as better access to specialist care and diagnostic testing were seen as the highest priorities. The identified suggestions focused mostly on the delays during referrals from primary to secondary care.

We concluded that many identified priorities were feasible, affordable and converged around common themes such as public awareness, care continuity and length of consultation.

Bringing together physical and mental health within primary care

Reducing fragmentation between different parts of the health system is a key priority for the National Health Service (NHS) and for health systems internationally, if they are to meet the challenges they face. One of the deepest fault-lines in the NHS is the disconnection of mental healthcare from the rest of the system; this has to be addressed as part of efforts to improve integrated care and make care more person centred.

In an article published in the Journal of the Royal Society of Medicine, Preety Das, Chris Naylor and I discuss this issue. Developing integrated approaches towards mental and physical health is increasingly becoming a policy priority; the report of the independent mental health taskforce to the NHS identified this as one of the top three priorities for the next five years. There has been recent investment in integrating mental and physical health within secondary care, for example, liaison psychiatry in acute general hospitals and perinatal mental healthcare. While such investment is also crucial, we believe that there is great unrealised opportunity for integration in developing new approaches to mental health within primary care.

Read the full article in the Journal of the Royal Society of Medicine.

Clinical impact of lifestyle interventions for the prevention of type 2 diabetes

In a study published in the journal BMJ Open, we reviewed the clinical outcomes of combined diet and physical activity interventions for people at high risk of type 2 diabetes. We looked at combined diet and physical activity interventions including ≥2 interactions with a healthcare professional, and ≥12 months follow-up. Our primary outcome measures included glycaemia, diabetes incidence. Secondary outcomes included behaviour change, measures of adiposity, vascular disease and mortality.

We identified 19 recent reviews for inclusion in our study. Most reviews reported that interventions were associated with net reductions in diabetes incidence, measures of glycaemia and adiposity. Small effect sizes and potentially transient effect were reported in some studies, and some reviewers noted that durability of intervention impact was potentially sensitive to duration of intervention and adherence to behaviour change. Behaviour change, vascular disease and mortality outcome data were infrequently reported, and evidence of the impact of intervention on these outcomes was minimal. Evidence for age effect was mixed, and sex and ethnicity effect were little considered.

We concluded that relatively long-duration lifestyle interventions can limit or delay progression to diabetes under trial conditions. However, outcomes from more time-limited interventions, and those applied in routine clinical settings, are more variable, in keeping with the findings of recent pragmatic trials. There is little evidence of intervention impact on vascular outcomes or mortality end points in any context. Hence, ‘real-world’ implementation of lifestyle interventions for diabetes prevention may be expected to lead to modest outcomes.

Priorities for the improvement of medication safety in primary care

Medication error is a frequent, harmful and costly patient safety incident. Research to date has mostly focused on medication errors in hospitals. In this study, we aimed to identify the main causes of, and solutions to, medication error in primary care. The resuls of the study were published in BMC Family Practice.

In the study, we used a novel priority-setting method for identifying and ranking patient safety problems and solutions called PRIORITIZE. We invited 500 North West London primary care clinicians to complete an open-ended questionnaire to identify three main problems and solutions relating to medication error in primary care. 113 clinicians submitted responses, which we thematically synthesized into a composite list of 48 distinct problems and 45 solutions. A group of 57 clinicians randomly selected from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians’ scores was presented using the average expert agreement (AEA). The study was conducted between September 2013 and November 2014.

The top three problems we identified were incomplete reconciliation of medication during patient ‘hand-overs’, inadequate patient education about their medication use and poor discharge summaries. The highest ranked solutions included development of a standardized discharge summary template, reduction of unnecessary prescribing, and minimisation of polypharmacy. Overall, better communication between the healthcare provider and patient, quality assurance approaches during medication prescribing and monitoring, and patient education on how to use their medication were considered the top priorities.

We identified a range of suggestions for better medication management, quality assurance procedures and patient education. According to clinicians, medication errors can be largely prevented with feasible and affordable interventions.

Should all GPs become NHS employees?

In a debate article in the BMJ, Laurence Buckman and I discuss the arguments for against GPs in England becoming NHS employees. Primary care in England’s NHS is in crisis. Recruitment of GPs is difficult throughout England, with many practices reporting vacant posts; many GPs are considering retiring early, and others want to cut down on their clinical work. The problems faced by GPs are partly due to the contracts that general practices have to provide NHS services and the way secondary care is organised. These contracts encourage the NHS to transfer work to primary care with the expectation that GPs will pick up this work at little or no extra cost. Most GPs would have no problem with taking on such work if they were given time to deal with it during their current working week. If GPs had employment contracts similar to NHS consultants they could have job plans, with time allocated for clinical work and for activities such as administration, teaching, training, and research.

Read the full article on the BMJ website.

Video consultations can improve both access to GPs and patient experience

The NHS should make better use of video consultations because they can boost patient access and save time and money for both patients and doctors, concludes preliminary research presented at this year’s International Forum on Quality & Safety in Healthcare in Kuala Lumpur (24-26 August).

Current challenges in the UK medical workforce are well known, making accessing a GP in a timely manner difficult, say the researchers (including myself) from Chelsea and Westminster Hospital NHS Foundation Trust and the Department of Primary Care and Public Health at Imperial College London.

The estimated total number of consultations in England rose from 224.5 million in 1995-6 to 303.9 million in 2008-9, with an average wait for a GP appointment of two weeks in some parts of the country. In light of these difficulties, weset up a trial video consultation clinic in two busy London general practices, with lists of nearly 10,000 patients.

Twice weekly video clinics were set up for 23 months to gauge the impact on patient access and to assess whether these could work alongside or possibly replace conventional face-to-face appointments. Initial doctor concerns included security and governance issues, while the absence of a physical examination worried some patients.

In all, 192 video consultations took place over the trial period. Only three patients didn’t attend their appointment compared with 576 no shows for face-to-face appointments over the same period.

Based on average appointment costs, this is a potential cost saving of £61,884 for just these two practices. We suggested that remote accessibility of video consultations and the reduction in travel time and delays might explain the findings.

The trial results prompted the practices to regularly offer video consultations. Traditional face-to-face appointments were available for patients with more long-term or complex health needs, to ensure that those needing more time with GPs accessed services appropriately.

“Clearly video consultations have a place in a health care system to improve access to primary care,” says the lead author Dr Mateen Jiwani. They offer an additional visual sensory component to consulting compared to telephone appointments, enabling clinicians to make safer decisions and carry out more effective triage, he added.

“With an increase in technology usage and remote socialising being the everyday norm, communicating with your doctor remotely will become a mainstay of future medical practice and self-care,” Dr Jiwani concludes. Evidently, the demand is there, he suggests.

Source: Jiwani M, Majeed A, Tahir A. The doctor will see you now….online. Presentation at the International Forum on Quality & Safety in Healthcare, 2017.

Read the news reports from Onmedica and the BMJ.

Government’s anti-immigration stance following the vote for Brexit alarms UK scientists

I was interviewed by the scientific journal Nature on the impact of the vote for Brexit and recent statements from government ministers on the recruitment and retention of scientific staff from outside the UK. I made the point that the success of our universities and their world-leading status depends in part on their ability to recruit leading scientists from across the globe. If this recruitment is threatened, then our universities – which make an essential contribution to our society – will be weakened.

Can GPs refuse to treat dental abscesses?

I was asked by the professional magazine medical Pulse to discuss the question of whether GPs can refuse to treat dental abscesses.

A study published in 2016 reported that around 600,000 consultations annually with GPs are for dental problems. Reasons why people present to GPs with dental problems include the poor provision of NHS dental services in many parts of England and the £19.70 charge that some patients must pay for a dental consultation.

If you decide that your patient may have a dental abscess, assuming there are no red flags (such as signs of spreading infection or sepsis) that would warrant an urgent referral for emergency hospital assessment, then the patient should be informed that they need to see a dentist. You should explain to the patient that a dentist is trained to treat dental abscesses but you are not. The dentist has the expertise and equipment needed to assess the patient, carry out suitable investigations (such as dental radiographs), and drain the abscess if this is required.

The dentist can also treat any underlying problems, through procedures such as root canal treatment or a tooth extraction, to minimise the risk of recurrence of the abscess. You should also explain to the patient that issuing an antibiotic is an inadvisable course of action for GPs for someone with a suspected dental abscess as this won’t address the underlying problem; may mask symptoms and result in a worse long-term outcome for the patient; and will encourage the development of antimicrobial resistance. If the patient does not have a regular dentist, inform them they can call NHS 111 or use the NHS Choices website to find the location of local services for emergency dental treatment.

It is NHS England and NHS commissioners, and not GPs, who are responsible for ensuring the population has access to adequate NHS dental services. This includes access to services for emergency dental treatment.

The published article can be read in Pulse, along with the views of two other doctors.