̽��ֱ�� of Cambridge - Martin Roland

No evidence to support claims that telephone consultations reduce GP workload or hospital referrals

sc604 — Wed, 27 Sep 2017 22:30:00 +0000

As UK general practices struggle with rising demand from patients, more work being transferred from secondary to primary care, and increasing difficulty in recruiting general practitioners, one proposed potential solution is a ‘telephone first’ approach, in which every patient asking to see a GP is initially phoned back by their doctor on the same day. At the end of this phone call the GP and the patient decide whether the problem needs a face-to-face consultation, or whether it has been satisfactorily resolved on the phone.

Two commercial companies provide similar types of management support for practices adopting the new approach, with claims that the approach dramatically reduces the need for face-to-face consultations, reduces workload stress for GPs and practice staff, increases continuity of care, reduces A&E attendance and emergency hospital admissions, and increases patient satisfaction.

Some of these claims are repeated in NHS England literature, including the assertion based on claims from one of the companies that practices using the approach have a 20% lower A&E usage and that “the model has demonstrated a cost saving of approximately £100k per practice through prevention of avoidable attendance and admissions to hospital”. Several Clinical Commissioning Groups have subsequently paid for the management support required for the approach to be adopted by practices in their area.

̽��ֱ��National Institute for Health Research (NIHR) acknowledged the need for robust and independent evaluation of current services and therefore commissioned the team led by Martin Roland, Emeritus Professor of Health Services Research at the ̽��ֱ�� of Cambridge. ̽��ֱ��results of the evaluation, which looked at data sources including GP and hospital records, patient surveys and economic analyses, are published today in ̽��ֱ��BMJ.

̽��ֱ��study found that adoption of the ‘telephone first’ approach had a major effect on patterns of consultation: the number of telephone consultations increased 12-fold, and the number of face-to-face consultations fell by 38%.

However, the study found that the ‘telephone first’ approach was on average associated with increased overall GP workload; there was an overall increase of 8% in the mean time spent consulting by GPs, but this figure masks a wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase.

Dr Jennifer Newbould from RAND Europe, part of the Cambridge Centre for Health Services Research, the study’s first author, says: “There are some positives to a ‘telephone first approach’; for example, we found clear evidence that a significant part of patient workload can be addressed through phone consultations. But we need to be careful about seeing this as a panacea: while this may increase a GP practice’s control over day-to-day workload, it does not necessarily decrease the amount of time GPs spend consulting and may, in some cases, increase it.”

̽��ֱ��researchers found no evidence that the approach substantially reduced overall attendance at A&E departments or emergency hospital admissions: introduction of the ‘telephone first’ approach was followed by a small (2%) increase in hospital admissions, no initial change in A&E attendance, but a small (2% per year) decrease in the subsequent rate of rise of A&E attendance. However, far from reducing secondary care costs, they found overall secondary care costs increased slightly by £11,776 per 10,000 patients.

Professor Roland adds: “Importantly, we found no evidence to support claims made by one of the companies that support such services – claims that have been repeated by NHS England – that the approach would be substantially cost-saving or reduce hospital referrals. This has resulted in some Clinical Commissioning Groups across England buying their consultancy services based on unsubstantiated claims. ̽��ֱ��NHS must be careful to ensure that it bases its information and recommendation on robust evidence.”

̽��ֱ��study was funded by the National Institute for Health Research.

Reference
Newbould, J et al. Tele-First. Evaluation of a ‘telephone first’ approach to demand management in English general practice: observational study. BMJ (2017). DOI: 10.1136/bmj.j4197

Telephone consultations to determine whether a patient needs to see their GP face-to-face can deal with many problems, but a study led by researchers at the Cambridge Centre for Health Services Research ( ̽��ֱ�� of Cambridge and RAND Europe), found no evidence to support claims by companies offering to manage these services or by NHS England that the approach saves money or reduces the number of hospital referrals.

̽��ֱ��NHS must be careful to ensure that it bases its information and recommendation on robust evidence.

Martin Roland

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Graduate, get a job … make a difference #7

ta385 — Tue, 19 Sep 2017 10:00:00 +0000

Gwilym Thomas (Trinity Hall), MB, Medicine (2015)

I graduated from Cambridge’s Medicine course in 2015 and I’m now working as a second year GP trainee, having already completed two years of post-qualification foundation training.

I’m currently based in A&E at the West Suffolk Hospital where my focus is on providing timely care and deciding whether someone can then return home or needs to be admitted for on-going treatment.

Junior doctors like me rotate jobs every four to six months so there is constant variety. Prior to A&E, I was working on a Care of the Elderly ward. I hope to be a GP within two to three years and during that time continue my involvement with Primary Care research.

My Motivation

I’m inspired by the positive impact I can make on the lives of patients and their families as part of a multidisciplinary team. I get particular satisfaction from taking a holistic approach, one of the tenets of GP training.

When I started at Cambridge, General Practice was near the bottom of my list of career options. I felt it might be repetitive and lacking in intellectual rigour, but actual experience completely changed my mind. In primary care I had such enthusiastic GP tutors and saw how embracing not just the biological but also psychological and social aspects of a patient’s problem could lead to better outcomes.

On the flipside, the biggest challenges I face are the long hours, difficult decisions and emotional challenges inherent in the job, alongside the wider issues in the NHS and social care.

What Cambridge did for me

̽��ֱ��Cambridge medical course is founded on core science which is later developed during clinical training, which seemed to match my learning style. In unfamiliar situations I can often problem-solve from first principles due to this sound scientific basis. It has also made me familiar with critically appraising evidence and that helps my clinical decision-making.

I discovered the world of primary care research, almost by accident, through Student Selected Components (SSC). Professor Jonathan Mant was my supervisor on my first Primary Care related SSC, which took me to the interface between stroke rehab in the hospital and community. Later, he encouraged me to submit an abstract to the Society for Academic Primary Care (SAPC) regional conference, and presenting there made me very enthusiastic about academic Primary Care. Professor Martin Roland, Dr Charlotte Paddison and Dr Katie Saunders supervised me on my second SSC in the Primary Care Unit. They gave me a lot of support to present again at SAPC, locally and nationally, and to publish the paper with which I won a Royal College of General Practitioners research prize in 2016.

My time at Cambridge proved so many of my preconceptions about primary care wrong. I soon learnt that GPs must use their clinical and diagnostic skills to make diagnoses, or deal with uncertainty, with fewer resources than available in hospital. I found there are also opportunities to develop specialist interests. My clinical placements were in various specialties and locations which helped me learn to integrate rapidly into a team and give me an insight into my eventual career plans. I also received really effective teaching in communication skills, which I continue to develop as a GP trainee.

During my 4th and 5th years, I spent several weeks with the practice team at Nene Valley Medical Practice in Peterborough, and that longitudinal placement really inspired and helped me to become a GP. During my elective in Scotland I received a lot of support and great advice from the anaesthetic department at Lorn and Islands Hospital in Oban. ̽��ֱ��short time I spent at the small, two-GP, Easdale Medical Practice, on the Isle of Seil also inspired me a great deal. Since graduating, the GPs at both Guildhall and Barrow Surgery in Bury St Edmunds, and the Grove Surgery in Thetford have been really supportive, friendly and knowledgeable. West Suffolk Hospital has been a good place to train as a junior doctor.

Applying to Cambridge

I grew up in Shepshed, a village in Leicestershire, and went to school in Loughborough. I was fortunate in having university-educated parents and in attending a school where Oxbridge applications were encouraged. But during my teenage years I had a lot of time out of school due to illness – I was diagnosed with Crohn's disease. I had to restart my GCSE year and, prior to returning, my head teacher advised me that either medicine or Oxbridge might be a realistic goal but, concerned for my health and welfare, they told me it might be best not to aim for both. I doubt they know how much that drove me to prove them wrong!

Crohn’s made the rest of school and the start of university a battle but I was open on my application about my illness and the potential for things to go wrong. I spoke to the ̽��ֱ��’s Disability Resource Centre team at an open day and my College also made me aware of all the support available if I needed it, which fortunately I rarely did. I did, however, receive targeted financial support via a Disabled Student's Allowance which made a huge difference to my confidence when I started at Cambridge. I have been in remission for some time now but being in some situations as both a patient and relative does, I think, help me approach things more holistically as a doctor.

It is really important with a medical degree to consider the course structure. While the traditional model at Cambridge suited me, it may not match everyone’s learning style. As for choosing a college, I didn't know where to start so decided to visit a shortlist on open day. I settled on Trinity Hall, where I felt most at home, a decision I’ve never regretted.

Cambridge graduates enter a wide range of careers but making a difference tops their career wish lists. In this series, inspiring graduates from the last three years describe Cambridge, their current work and their determination to give back.

My time at Cambridge proved so many of my preconceptions about primary care wrong.

Gwilym Thomas, MB, Medicine (2015)

Find out more

For more information about studying Medicine at Cambridge.

Find out more about General Practice as a career.

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South Asian patients have worse experiences of GP interactions, study suggests

cjb250 — Thu, 15 Sep 2016 08:11:54 +0000

Patients’ evaluations of doctors’ interpersonal skills are used to assess quality of care. In both the UK and the US, certain minority ethnic groups report lower patient experience scores compared to the majority population. For example, the English General Practice Patient Survey found that South Asian groups report particularly low scores compared to the White British majority, with Bangladeshi and Pakistani groups providing the lowest scores.

Several potential explanations have been proposed for these lower ratings. These mainly relate to whether South Asian patients receive lower quality care, or whether they receive similar care, but rate this more negatively.

To explore whether the low scores reflect a genuinely poor experience, researchers at the Centre for Health Services Research, ̽��ֱ�� of Cambridge, showed 564 White British and 564 Pakistani adults a series of films showing typical clinical scenarios. They were asked to rate how good the GP was at various measures: giving sufficient time and listening to the patient in the the film, explaining the tests and treatment, involving the patients in decisions about care and treating them with care and concern.

Based on the participants’ responses, the researchers then gave a score out of 100 for how positively the participants had judged the GP’s performance in the vignettes. ̽��ֱ��results of the study, funded by the National Institute for Health Research, are published in the journal BMJ Open.

̽��ֱ��scores from Pakistani participants were typically higher than those from White British participants when they’d seen the same video. ̽��ֱ��mean communication score from Pakistani participants was 67 of 100, ten points higher than the mean score from White British participants. When adjusted for age, gender, deprivation, self-rated health, and video, the difference increased to 11 points. ̽��ֱ��largest differences were seen when participants were over 55 years old.

“Given that Pakistani adults tend to have a more positive take on the same vignettes viewed by their White British counterparts, we can only conclude that the low scores they give in national surveys do genuinely reflect worse care,” says Dr Jenni Burt from the Cambridge Centre for Health Services Research at the ̽��ֱ�� of Cambridge.

“To some extent, this may reflect challenges arising from language barriers and poorer health literacy, but this is unlikely to explain all of the variations in care. These findings very clearly show that there are major inequalities in care for minority ethnic groups.”

Professor Martin Roland, Emeritus Professor of Health Services Research at the ̽��ֱ�� of Cambridge, adds: “Understanding why minority ethnic groups often give poorer evaluations of care is critical to helping health services improve the services they offer to their patients. We need more research now that focuses on how factors such as language barriers, health literacy, discrimination and system-level failures that combine to create inequalities that affect South Asian people.”

Reference
Burt, J et al. Understanding negative feedback from South Asian patients: experimental vignette study. BMJ Open; 8 Sept 2016; DOI: 10.1136/bmjopen-2016-011256

Communication between doctors and South Asian patients is poor, according to national GP surveys, but a question has been raised about whether this reflects genuinely worse experiences or differences in responding to questionnaires. Now, a new study led by researchers at the ̽��ֱ�� of Cambridge has shown that it is in fact the former – South Asian patients do experience poorer communication with their GP than the White British majority.

Given that Pakistani adults tend to have a more positive take on the same vignettes viewed by their White British counterparts, we can only conclude that the low scores they give in national surveys do genuinely reflect worse care

Jenni Burt

Jasleen Kaur

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If general practice fails, the whole NHS fails, argue healthcare experts

cjb250 — Thu, 18 Feb 2016 09:11:25 +0000

Hospitals’ £2bn deficit “certainly sounds dramatic”, they argue, “but hospitals don’t go bust – someone usually picks up the bill.” General practice doesn’t have that luxury, and its share of the NHS budget has fallen from 11% in 2006 to under 8.5% now.

Recent research shows that GPs are experiencing unprecedented levels of stress with increasing workload and overwhelming bureaucracy. A GP’s comment at a recent national conference encapsulates the sense of despair: “ ̽��ֱ��pressure of work leaves me in constant fear of making mistakes”.

GPs are finding it harder to recruit trainees and to find partners to replace those increasingly retiring in their 50s.

Politicians and NHS leaders want more care to be moved into primary care, yet the share of funding devoted to general practice is falling as a high proportion of the NHS budget is channelled into hospitals, and in the past 10 years, the number of hospital consultants has increased at twice the rate of GPs.

GPs currently manage the great majority of patients without referral or admission to hospital but if this balance shifted only slightly, hospitals would be overwhelmed.

“It is general practice that makes the NHS one of the world’s most cost effective health services,” they say. ̽��ֱ��£136 cost per patient per year for unlimited general practice care is less than the cost of a single visit to a hospital outpatient department.

̽��ֱ��authors, who are both internationally renowned experts in general practice, present a number of solutions. They say GPs need a “substantial injection of new funding” to provide more staff in primary care.

In addition, new roles are needed to take the “strain off” clinical staff, for example, physician associates, pharmacists, and advanced practice nurses. They also argue that reviews of practices’ contracts that threaten serious financial destabilisation should be put on hold while a fair funding formula is developed to replace the 25 year old ‘Carr-Hill’ formula.

NHS England should tackle spiralling indemnity costs by providing Crown Indemnity similar to that for hospital doctors, as GPs increasingly do work previously done by specialists.

Bureaucracy should be slashed, in part by changing the £224m Care Quality Commission inspection regime to one where only the 5-10% of practices found to be struggling are revisited within five years.

In hospitals, the ‘Choose and Book’ referral system needs radical reform – the authors estimate that communicating by phone, email, and online video link could reduce outpatient attendance by as much as 50% in some specialties. And the ‘Payment by Results’ system for funding hospitals must become a population based, capitated budget that incentivises hospitals to support patients and clinicians in the community.

̽��ֱ��authors identify two ‘elephants in the room’ that can no longer be ignored. First, cuts to social care make it increasingly difficult for hospitals to discharge patients.

Second, the UK’s funding for healthcare has fallen well behind its European neighbours – now thirteenth out of 15 in healthcare expenditure as a percentage of gross domestic product. In 2000, Tony Blair promised to raise NHS spending to mid-European levels. Today, this would require another £22bn a year.

“Urgent action is needed to restore the NHS,” warn the authors. “But the crisis will not be averted by focusing on hospitals. If general practice fails, the whole NHS fails.”

Professor Martin Roland, Professor of Health Services Research at the ̽��ֱ�� of Cambridge, adds: “GPs need to feel valued rather than continually criticised by politicians and regulators. Many other countries see primary care as the jewel in the crown of the NHS, yet many practices are at breaking point, with an increasing number simply handing in their contracts and closing.”

Sir Sam Everington, Tower Hamlets GP and chair of Tower Hamlets CCG, says: “Patients really value the support of their family doctor, particularly in crises like end of life care. Moving care into the community means supporting patients to die at home surrounded by their loved ones – this is one of many reasons why family medicine is critical to the NHS.

“Family medicine and new developments like social prescribing show the strengths of general practice in supporting vulnerable patients in all aspects of their physical and mental well-being.”

Reference
Martin Roland and Sam Everington. Tackling the crisis in general practice. ̽��ֱ��BMJ. 18 Feb 2016. dx.doi.org/10.1136/bmj.i942

Adapted from a press release by ̽��ֱ��BMJ.

̽��ֱ��current focus on financial crises in hospitals diverts attention from the crisis in general practice, argue Professor Martin Roland from the ̽��ֱ�� of Cambridge and GP Sir Sam Everington in an editorial published in ̽��ֱ��BMJ today.

tiarescott

Dr Jay Gordon (cropped)

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Changes to NHS policy unlikely to reduce emergency hospital admissions

cjb250 — Fri, 29 Jan 2016 07:48:54 +0000

Alternative approaches are therefore needed to tackle the continuing rise of costly emergency admissions, conclude researchers from the Health Research Board Centre for Primary Care Research at the Royal College of Surgeons in Ireland (RCSI) in collaboration with the ̽��ֱ�� of Cambridge.

Recently introduced changes to GPs’ pay mean that they are now incentivised to identify people in their practice thought to be at high-risk of future emergency admission and offer extra support in the form of ‘case-management’, including personalised care plans. However, the researchers show that emergency admission is a difficult outcome to predict reliably. Electronic tools have been developed to identify people at high-risk but these tools will, at best, only identify a minority of people who will actually be admitted to hospital. In addition, the researchers found that there is currently little evidence that implementing case management for people identified as high-risk actually reduces the risk of future emergency admission.

̽��ֱ��authors suggest alternative options that may have more impact on the use of hospital beds for patients following an emergency admission, based on the research evidence in this area.

One recommendation is to focus on reducing the length of time that patients are in hospital – though this depends on resources being available in the community to support patients when they are discharged. Second, a significant proportion of all emergency admissions are re-admissions to hospital following discharge and research evidence supports interventions to reduce some of these admissions, especially when several members of the healthcare team (e.g. doctor, nurse, social worker, case manager) are involved in helping patients manage the transition from hospital to home.

A third option is to focus on certain medical conditions, such as pneumonia, known to cause avoidable emergency admissions and more likely to respond to interventions in primary care. Finally, the authors suggest that policy efforts should be concentrated in more deprived areas where people are more likely to suffer with multiple chronic medical conditions and are more likely to be admitted to hospital.

Lead author and Health Research Board Research Fellow Dr Emma Wallace from the RCSI said: “Reducing emergency admissions is a popular target when trying to curtail spiralling healthcare costs. However, only a proportion of all emergency admissions are actually avoidable and it’s important that policy efforts to reduce emergency admissions are directed where they are most likely to succeed.

“Our analysis indicates that current UK healthcare policy targeting people identified as high risk in primary care for case management is unlikely to be effective and alternative options need to be considered.”

Professor Martin Roland, senior author and Professor of Health Services Research at the ̽��ֱ�� of Cambridge, added: “Too often government policy is based on wishful thinking rather than on hard evidence on what is actually likely to work, and new interventions often aren’t given enough time to bed in to know whether they’re really working.

“Reducing the number of people who are readmitted to hospital, and reducing the length of time that people stay in hospital are both likely to have a bigger effect on hospital bed use than trying to predict admission in the population. Both of these need close working between primary and secondary care and between health and social care.”

Reference
Wallace, E et al. Reducing emergency admissions through community-based interventions: are uncertainties in the evidence reflected in health policy? BMJ; 28 Jan 2016

Recent changes to UK healthcare policy intended to reduce the number of emergency hospital admissions are unlikely to be effective, according to a study published in the British Medical Journal.

Too often government policy is based on wishful thinking rather than on hard evidence on what is actually likely to work, and new interventions often aren’t given enough time to bed in to know whether they’re really working

Martin Roland

Lydia

Emergency Ambulance (cropped)

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Improving access to GP surgeries could reduce burden on out-of-hours services

cjb250 — Wed, 21 May 2014 22:30:00 +0000

Out-of-hours primary care services – such as a telephone consultation followed by a home visit or attendance at an out-of-hours centre – present several disadvantages compared to in-hours services. Not only are these services more expensive to the NHS, but maintaining the high standards of care and patient experience out-of-hours is challenging. In part this is because patients using out-of-hours services will often be seen by doctors unfamiliar with their potentially complex case histories. For these reasons, modern healthcare systems aim to reduce demand for out-of-hours primary care.

In a study published in the Emergency Medicine Journal, researchers from the ̽��ֱ�� of Cambridge and the ̽��ֱ�� of Exeter Medical School analysed data from almost 570,000 respondents to the 2011/2012 English General Practice Patient Survey to see why people used out-of-hours services and to identify ways of reducing this burden.

̽��ֱ��researchers found that a proportion of patients faced a number of potential barriers to accessing GP surgeries including an ability to get through to the surgery on the telephone or to get an appointment, urgent or otherwise, as well as inconvenient opening hours. ̽��ֱ��patients who experience these difficulties have a higher chance of resorting to the use of out-of-hours primary care services.

7.5% of respondents reported using out-of-hours services in the previous six months though not all of these were due to difficulties in accessing regular GP services. ̽��ֱ��researchers estimate that optimising access to in-hours services would reduce this to 6.7%, a relative reduction of 11%.

Dr Yin Zhou from the Cambridge Centre for Health Services Research says: “ ̽��ֱ��use of out-of-hours services is not ideal for the patient and can be costly to the NHS. If we’re to reduce the burden on the NHS and improve patient care, then we need to make improvements in providing access to GP surgeries.”

Contrary to expectations, the researchers found that the association between out-of-hours use and the convenience of surgery opening hours was stronger amongst people in part-time than those in full-time work or education. In other words, even when opening hours suited people in part-time work, they were more likely to attend out-of-hours services than those in full-time work or education.

Professor Martin Roland, Director of the Centre, adds: “Our research suggests that improving access to regular services is not as straightforward as just extending opening hours, which current Government policies favour. Even those in part-time work can struggle to get an appointment, so offering greater availability during regular surgery hours would help reduce use of out-of-hours services.”

̽��ֱ��study was funded by the East of England Multi-Professional Deanery, the Department of Health and the National Institute of Health Research.

Poor access to GP surgeries could be driving patients to use out-of-hours services and putting an extra burden on the NHS, according to researchers at the Cambridge Centre for Health Services Research. In research published today, they say that improving access could lead to an 11% reduction in the use of out-of-hours primary care services.

Improving access to regular services is not as straightforward as just extending opening hours, which current Government policies favour

Martin Roland

Julian Claxton Photography, Wellcome Images

GP consultation with a female patient

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