̽��ֱ�� of Cambridge - Cambridge Centre for Health Services Research

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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Cambridge awarded £40m to create world-leading health care improvement research institute

cjb250 — Tue, 28 Mar 2017 08:59:33 +0000

This is the charity’s single largest grant to date and will create an institute that is the first of its kind in Europe.

Led by Mary Dixon-Woods, RAND Professor of Health Services Research and Wellcome Trust Investigator at the ̽��ֱ�� of Cambridge, the institute will work closely with a wide range of partners across the UK including RAND Europe and Homerton College, Cambridge. Seeking to strengthen the evidence-base for how to improve health care, it will produce practical, high quality learning about how to improve patient care and will grow capacity in research skills in the NHS, academia and beyond.

̽��ֱ��Health Foundation says it is making this significant investment because it recognises the huge potential for research to shed light on how sustainable and replicable improvements to the quality of patient care can be made in the NHS more quickly.

Dr Jennifer Dixon, chief executive of the Health Foundation, says: “Faster learning and discovery is vital to achieving higher quality health care for patients at a sustainable cost. That is why the Health Foundation is making its biggest single grant to date to help build the field of improvement research.

“ ̽��ֱ�� ̽��ֱ�� of Cambridge and their partners have set out a compelling vision for this ground-breaking improvement research institute – the first of its kind in Europe. This is a significant and exciting step in developing evidence on a massive scale across the NHS about what works to improve patient care. Critically, the institute’s work will include understanding not only which interventions work, but also in which contexts and why.”

Professor Dixon-Woods adds: “ ̽��ֱ��NHS, like health systems around the world, is faced with pressing challenges of quality and safety. Yet the science of how to make improvements has remained under-developed. This funding is a tremendous opportunity to produce new knowledge about how to improve care, experience and outcomes for patients. Together with our partners, the ̽��ֱ�� of Cambridge is hugely excited at the chance to work with NHS staff, patients and carers to identify, design and test improvements.”

̽��ֱ��institute will formally launch within the next year and will be based at the Cambridge Biomedical Campus, alongside Cambridge ̽��ֱ�� Hospitals NHS Foundation Trust and world-leading research institutes.

For more information, please visit the Health Foundation's website.

Adapted from a press release from the Health Foundation.

̽��ֱ�� ̽��ֱ�� of Cambridge is to receive £40 million over ten years from the Health Foundation, an independent charity, to establish and run a new research institute aimed at strengthening the evidence-base for how to improve health care.

This funding is a tremendous opportunity to produce new knowledge about how to improve care, experience and outcomes for patients

Mary Dixon-Woods

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Concerns over wasting doctor’s time may affect decision to see GP

cjb250 — Tue, 07 Feb 2017 09:11:57 +0000

In the study, published today in the journal Social Science and Medicine, researchers from the Cambridge Centre for Health Services Research report how the theme of ‘wasting doctors’ time’ arose so often during interviews conducted with patients about their experiences of primary care that they chose to study this topic in its own right.

“‘Am I wasting the doctor’s time?’ is a question that many patients ask themselves when deciding whether or not to visit the doctor,” explains Dr Nadia Llanwarne, who led the study. “We already knew that this worry existed among some patients, but this is the first study entirely dedicated to the subject that reports the existence of this worry among a variety of patients, young and old, healthy and sick, visiting their GP for a wide range of complaints.”

As part of the study, Dr Llanwarne and colleagues filmed patients’ consultations with their GPs and then interviewed 52 patients across GP surgeries in London, the east of England and south west England about their experience. It was in these interviews that the issue of timewasting arose.

̽��ֱ��researchers identified three threads common to the issue of timewasting present across patients’ narratives in general practice: the experience of a conveyor belt approach to care, the intimation that ‘other patients’ waste time, and uncertainty among patients over what is worthy of their doctor’s time.

̽��ֱ��authors consider the reasons why people appear concerned about timewasting. Patients spoke of the pressured context in which their consultations take place: the demand on services, the NHS’s limited resources, the lack of time, and busy doctors. Understanding the time pressures that doctors face, patients described how these challenges influenced their decision to see their GP.

In an overstretched NHS, time becomes all the more precious, and this has meant that public campaigns often refer to appropriate and inappropriate users. For decades, doctors have expressed frustration that too many patients visit unnecessarily. As a result of these judgments cast upon them, patients voice the pressure to consult only when necessary and speak openly of ‘timewasters’.

“Patients are keen to avoid this label, but neither the patients, nor the doctors, are able to clearly define what precise problems might attract such a label,” says Dr Llanwarne. “This is because some patients will present with what seems on the surface a minor problem, but once through the door of the doctor’s consulting room, they may open up about more serious complaints. With some symptoms it may be very difficult for the patient to know whether these are serious enough or not to need review by the doctor.

“Recognising this worry about timewasting among patients is important because it could influence whether a patient chooses to see the doctor or not. If a patient decided to hold off seeing the doctor for fear of wasting resources, this could have serious implications for their health.”

Dr Llanwarne adds: “It’s important for patients to not delay contacting their doctor simply because of worry about wasting doctors’ time. And it’s important for doctors to be attentive to the fact that many patients will be worried about this. Doctors can then ensure they allay patients’ concerns when they do seek help.”

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

Reference
Llanwarne, N et al. Wasting the doctor's time? A video-elicitation interview study with patients in primary care. Social Science & Medicine; e-pub 18 January 2017; DOI: 10.1016/j.socscimed.2017.01.025

Worries over wasting their doctor’s time, particularly at a time when NHS resources are stretched, may influence when and whether patients choose to see their GP, according to a study carried out by the ̽��ֱ�� of Cambridge.

Recognising this worry about timewasting among patients is important because it could influence whether a patient chooses to see the doctor or not. If a patient decided to hold off seeing the doctor for fear of wasting resources, this could have serious implications for their health

Nadia Llanwarne

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Keeping patients safe in hospital

cjb250 — Tue, 15 Nov 2016 09:39:09 +0000

In November 2004, Mary McClinton was admitted to Virginia Mason Medical Center in Seattle, USA, to receive treatment for a brain aneurysm, a potentially serious swelling in a blood vessel. What followed was a tragedy, made worse by the fact that it was entirely preventable.

McClinton was mistakenly injected with the antiseptic chlorhexidine. It happened, the hospital says, because of “confusion over the three identical stainless steel bowls in the procedure room containing clear liquids — chlorhexidine, contrast dye and saline solution”. Doctors tried amputating one of her legs to save her life, but the damage to her organs was too great: McClinton died 19 days later.

Nine years on, an almost identical accident occurred at Doncaster Royal Infirmary in the UK. Here, the patient, ‘Gina’, survived, but only after having her leg amputated.

Professor Mary Dixon-Woods is one of Cambridge’s newest recruits, and she is on a mission: to improve patient safety in the National Health Service and in healthcare worldwide. She has recently taken up the role as RAND Professor of Health Services Research, having moved here from the ̽��ֱ�� of Leicester.

It is, she admits, going to be a challenge. Many different policies and approaches have been tried to date, but few with widespread success, and often with unintended consequences.

Financial incentives are widely used in the NHS and in the USA, but recent evidence suggests that they have little effect. “There’s a danger that they tend to encourage effort substitution – what people often refer to as ‘teaching to the test’,” explains Dixon-Woods. In other words, people focus on the areas that are being incentivised, but neglect other areas. “It’s not even necessarily conscious neglect. People have only a limited amount of time, so it’s inevitable they focus on areas that are measured and rewarded: it’s an economy of attention as much as anything else.”

In 2013, Dixon-Woods and colleagues published a study, funded by the Wellcome Trust, evaluating the use of surgical checklists introduced in hospitals to reduce complications and deaths during surgery. ̽��ֱ��checklists have become the most widely used patient safety intervention in the world and are recommended by the World Health Organization. Yet, the evidence shows that checklists may have little impact, and her research found that in some situations – particularly in low-income countries – they might even make things worse.

“ ̽��ֱ��checklists sometimes introduced new risks. Nurses would use the lists as a box-ticking exercise rather than as a true reflection of events – they would tick the box to say the patient had had their antibiotics when there were no antibiotics in the hospital, for example.” They also reinforced the hierarchies – nurses had to try to get surgeons to do certain tasks, but the surgeons used it as an opportunity to display their power and refuse.

Problems are compounded by a lack of standardisation. Dixon-Woods and her team spend time in hospitals to try to understand which systems are in place and how they are used. Not only does she find differences in approaches between hospitals, but also between units and even between shifts. “Standardisation and harmonisation are two of the most urgent issues we have to tackle. Imagine if you have to learn each new system wherever you go or even whenever a new senior doctor is on the ward. This introduces massive risk.”

One place that has managed to break this pattern is Northern Ireland, which has overcome the problem of poor labelling of lines such as intravenous lines and urinary catheters

Even when an institution manages to make genuine improvements in patient safety, too often these interventions cannot be replicated elsewhere or scaled up, leading to the curse of “worked once”, as she describes it.

One place that has managed to break this pattern is Northern Ireland, which has overcome the problem of poor labelling of lines such as intravenous lines and urinary catheters. A sick patient may have several different lines attached to them; these were not labelled in any consistent way – if at all – so a nurse might use the wrong line or leave a line in place too long, risking infection. Over 18 months, the health service in Northern Ireland came up with a solution. Soon, whether you are in a hospital, a nursing home or a hospice, every line will be labelled the same way.

“I’m interested in how they managed to achieve that and what we can learn that can be used in the next place that wants to standardise their lines.”

Dixon-Woods compares the issue of patient safety to that of climate change, in the sense that it is a “problem of many hands”, with many actors, each making a contribution towards the outcome, and where it is difficult to identify who has responsibility for solving the problem. “Many patient safety issues arise at the level of the system as a whole, but policies treat patient safety as an issue for each individual organisation.”

Nowhere is this more apparent than the issue of ‘alarm fatigue’. Each bed in an intensive care unit typically generates 160 alarms per day, caused by machinery that is not integrated. “You have to assemble all the kit around an intensive care bed manually,” she explains. “It doesn’t come built as one like an aircraft cockpit. This is not a problem a hospital can solve alone. It needs to be solved at the sector level.”

Dixon-Woods has turned to Professor John Clarkson in Cambridge’s Engineering Design Centre to help. Clarkson has been interested in patient safety for over a decade; in 2004, his team published a report for the Chief Medical Officer entitled ‘Design for patient safety – a system-wide design-led approach to tackling patient safety in the NHS’.

We need to look through the eyes of the healthcare providers to see the challenges and to understand where tools and techniques we use in engineering may be of value
John Clarkson

“Fundamentally, my work is about asking how can we make it better and what could possibly go wrong,” explains Clarkson. It is not, he says, just about technology, but about the system and the people within the system. When he trains healthcare professionals, he avoids using words like ‘risk’, which mean different things in medicine and engineering, and instead asks questions to get them thinking about the system.

“We need to look through the eyes of the healthcare providers to see the challenges and to understand where tools and techniques we use in engineering may be of value. I have no doubt that if you were to put a hundred engineers into Addenbrooke’s [Hospital], you could help transform its care.”

There is a difficulty, he concedes: “There’s no formal language of design in healthcare. Do we understand what the need is? Do we understand what the requirements are? Can we think of a range of concepts we might use and then design a solution and test it before we put it in place? We seldom see this in healthcare, and that’s partly driven by culture and lack of training, but partly by lack of time.”

Dixon-Woods agrees that healthcare can learn much from how engineers approach problems. “Medical science tends to prioritise trials and particular types of evidence, whereas engineering does rapid tests. Randomised controlled trials do have a vital role, but on their own they’re not the whole solution. There has to be a way of getting our two sides talking.”

Only then, she says, will we be able to prevent further tragedies such as the death of Mary McClinton.

Healthcare is a complex beast and too often problems arise that can put patients’ health – and in some cases, lives – at risk. A collaboration between the Cambridge Centre for Health Services Research and the Department of Engineering hopes to get to the bottom of what’s going wrong – and to offer new ways of solving the problems.

Standardisation and harmonisation are two of the most urgent issues we have to tackle. Imagine if you have to learn each new system wherever you go or even whenever a new senior doctor is on the ward. This introduces massive risk

Mary Dixon-Woods

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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

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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.

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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

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Antidepressants and pain killers: should we be worried?

cjb250 — Wed, 15 Jul 2015 08:00:15 +0000

Many of us frequently take pain killers to relieve our headaches, to soften joint pains or to reduce the symptoms of a cold. Some of these drugs – for example, ibuprofen, but not paracetamol – are from a class of drugs known as non-steroidal anti-inflammatory drugs (NSAIDs). These medicines are very commonly used – in fact, they are amongst the top-twenty most frequently prescribed medications in UK primary care. Non-prescription use is also widespread, with many products available off the shelf in supermarkets and without oversight from a pharmacist.

Antidepressants medication use is also commonplace, although in the UK these are prescription only medicines. Importantly, depression and chronic pain frequently co-exist: roughly a third of those with a painful condition also experience depression, and over a quarter of those suffering depression also complain of pain.

A paper out this week in the BMJ has identified an increased risk of brain haemorrhage from the combined use antidepressants and NSAIDS. This will understandably raise concerns amongst both doctors and the public. But is it that straightforward?

There is already an established risk of gastrointestinal bleeding, for example in the lining of the stomach, with this combination of drugs – probably greater than the newly identified risk of brain haemorrhage. Yet it is likely many GPs (and probably other doctors) remain unaware of this problem, and it does not influence the majority of prescribing behaviour anyway. So does this new found problem matter, or will it be interpreted by many as simply relatively unfounded scaremongering?

We mustn’t lose sight of the fact that the risk of brain haemorrhage is still low: over a period of 30 days taking both antidepressants and NSAIDS, only one person in every 2,000 would be affected. And given the absolute benefits of antidepressants and NSAIDs are generally not easily quantified, and need to be interpreted in the context of the individual’s personal psychological and social circumstances, the balance of harm and benefit remains uncertain.

Doctors will also understandably ask what the alternatives are: there are limited options for chronic pain relief, and NHS access to psychological treatments for depression (for example cognitive behavioural therapy, CBT), is generally poor. Patients’ quality of life will often be significantly diminished by stopping these medicines.

And there are several important unanswered questions remaining. What are the longer-term risks, beyond the first month examined by the current study? What is the risk of the drugs when used separately? And can these findings from an East-Asian population be generalized to the rest of the world, given what we know that people of different ethnic backgrounds often respond to medicines differently? There is a need for further research to answer these uncertainties.

Overall, this new paper identifies a potential small risk of adverse consequences of combining two common drugs, but unresolved queries remain. For now, if people are worried about the medications they are taking, they should discuss their concerns with their doctor, even if doctors then find themselves in the difficult position of trying to explain the uncertain balance of risks and benefits to patients.

But these issues are also important and very relevant to the safe and rational use of medicines more generally. It is not uncommon for patients to be affected by more than one condition – depression, arthritis, diabetes, heart disease, for example – and hence taking a mixture of drugs. We need further research to better understand the challenges associated with using combinations of medicines in people with multiple health conditions.

Reference
Risk of intracranial haemorrhage linked to co-treatment with antidepressants and NSAIDs. BMJ; 15 July 2015

New research has identified an increased risk of brain haemorrhage from the combined use of antidepressant medicines and medicines such as ibuprofen. Should we be worried? Dr Rupert Payne from the Cambridge Centre for Health Services Research looks at the evidence.

If people are worried about the medications they are taking, they should discuss their concerns with their doctor

Rupert Payne

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