Monthly Archives: April 2016

General practice in meltdown: it’s not just funding

Des Spence

Des Spence

Des Spence is a GP in Maryhill, Glasgow.
Des Spence

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You can download the PDF and comment on this article in the May issue of the BJGP available at bjgp.org.

General practice is in crisis. One in three training posts are empty, 10% of GP positions are unfilled and this is worsening daily.1,2 Practices are closing their lists but this is merely deflecting the pressures elsewhere. And with 25% of male GPs (many who work full time) over 55, the pressure is set to get a whole lot worse.3 The more pressure, the less attractive GP is becoming. But there is no cavalry over the horizon, for unlike crises of the past, it doesn’t seem fixable. This situation has nothing to do with ‘the Tories’ nor the nastiness of the Daily Mail, for its roots lie elsewhere. Why is a career in general practice no longer desirable?

There was a big expansion in hospital consultant numbers, 40% in a decade.4 With increasing opportunities to work part time, currently 38% of female consultants choose to do so.4The pay is good with opportunities to work privately, do research, attend conferences, teaching and management. Out of hours working is much less onerous than in the past and consultants are shielded by junior staff. Hospital medicine is an attractive career.

General practice has changed little, with only a 16% expansion in numbers.4 Ten minute appointments, an excess of 30 patients a day, uncertainty, accessibility and a chaotic working environment. GPs work in small and often dysfunctional groups, where sickness absence can make the workload unmanageable. New GPs can either become a partner with all the headaches that this entails or take a salaried position with all the limitations that entails. An undervalued and dead end career for many. Out of hour services are breaking down across the country, many are disorganised and shambolic. No amount of money would entice many GPs to work in these organisations. GP is an unattractive career.

But there is a fundamental professional issue limiting GP recruitment. In England, 29% of students were privately educated and a further 22% came from selective grammar schools. In Scotland only 4.3% of medical students came from the poorest 20% of postcodes and 86% have parents for a professional group.5 We are a profession choosing those in our own image.6 Medical schools’ attempts at social inclusion are mere tokenism and we are wasting talent. The truth is a medical degree is often about middle class aspiration and this is killing general practice. Deans shamelessly promote an obsession with status, telling medical students don’t “fail and become GPs”.7 These pernicious negative attitudes against GPs are everywhere. Our hospitals echo to the sound of patronising laughter directed at GPs. Doctors are not choosing general practice because of its low status. Are medical schools failing general practice and choosing the wrong people ?

Is there a solution? More money might help with general practice receiving a meagre 7% of the NHS budget.8 (Governments can’t resist the glamour of a shiny new hospital.) But if we can’t recruit GPs then what difference will more money make? More resources in the form of nursing support would help but there is a limit on how much medical work can be substituted by nurses. Fundamentally GPs need a better working environment and more opportunities. A radical restructuring with bigger better organised practices, units of 30,000-50,000 patients is needed. This will afford economies of scale, diversification in careers, more standardisation, and much less chaotic working. Larger groups have stronger advocacy in seeking resources.

We need to challenge the institutional negativity towards GPs in medical schools and hospitals. GP trainees completing foundation years should train exclusively within general practice. Hospital placements are frequently clinically irrelevant to general practice. General practice specialist training should be the same length as other specialists. We need more GP academic departments, more involvement in undergraduate training and all foundation year doctors should rotate through GP.

Most importantly we need a large expansion of medical student numbers, with affirmative action on social mobility. Medical student places have a limited supply and high demand, thus artificially elevating its status. But medicine is not especially academically challenging and there are plenty of suitably qualified applicants.

You never value what you have till you’ve lost it, a collapse in primary care wouldn’t just be bad medicine, but a calamity for the NHS.

References

1. One in 3 trainee GP posts are empty, amid warnings of crisis shortage. 06 Apr 2015. Daily Telegraph http://www.telegraph.co.uk/news/health/news/11517019/One-in-3-trainee-GP-posts-are-empty-amid-warnings-of-crisis-shortage.html

2. Sofia Lind. GP vacancy rate at highest ever, with 50% rise in empty posts. Pulse 29 April 2015 http://www.pulsetoday.co.uk/your-practice/practice-topics/employment/gp-vacancy-rate-at-highest-ever-with-50-rise-in-empty-posts/20009835.fullarticle

3. David N Blane, Gary McLean and Graham Watt. Distribution of GPs in Scotland by age, gender and deprivation. Scottish Medical Journal 2015 http://scm.sagepub.com/content/early/2015/09/22/0036933015606592.full.pdf

4. Medical Workforce September 2013 BMA http://www.bma.org.uk

5. Steven K Fair access to medicine? Retrospective analysis of UK medical schools application data 2009-2012 using three measures of socioeconomic status. BMC Medical Education 2016 16:11 http://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-016-0536-1

6. Fair Access to Professional Careers. A progress report by the Independent Reviewer on Social Mobility and Child Poverty. May 2012

7. Alex Matthews-King. Medical schools warn students: ‘Fail and become GPs’ Pulse 24 March 2015 http://www.pulsetoday.co.uk/your-practice/practice-topics/education/medical-schools-warn-students-fail-and-become-gps/20009498.fullarticle

8. Sarah Lafond. Current NHS spending in England the Health Foundation. Jan 2015

GP Journal Club: the primary care–secondary care battleground

Sampson R, Barbour R and Wilson P. The relationship between GPs and hospital consultants and the implications for patient care: a qualitative study. BMC Fam Pract 2016. 17:(1): 1-12

The next GP Journal Club is on the 8th May at 8pm. You can download the paper here.

image1Rammya Mathew is an academic GP at UCL and is chairing the next GP Journal Club.

Sampson et al have done a fantastic job of characterising the somewhat strained relationships that exist across the primary care-secondary care interface. On reading the paper, I couldn’t help but feel that so much of the narrative rings true of my own experiences on the frontline. I am well aware of the difficulties we face in primary care and how it can sometimes feel as though we are on the battlefield with our hospital colleagues. However, we often fail to realise that they have their own frustrations regarding our working practices, and whilst we are both seeing the situation from our own perspectives, it is indeed the patient who becomes the victim of unintended combat.

I find it incomprehensible that we are supposedly working together for our patients, but at the same time, we struggle to pick up the phone and talk to each other. There have been times when I have patiently listened to an automated switchboard message for a whole three and a half minutes in the middle of a busy morning surgery, only to then be greeted by the glaring beep of an ominous dead tone. But what if our hospital colleagues want to speak to us – between jam-packed surgeries that are sandwiched with home visits, when do we make ourselves available to them? With an ever increasing workload, it sometimes seems unimaginable that we might be able to create the time and/or space required to enable meaningful dialogue between primary and secondary care.

In my experience, working together breeds a great sense of satisfaction but there are certain do’s and don’t, which have to be respected. I’m sure that on both sides of the fence, we are cautious of not allowing our egos to get in the way of good patient care. But when does integrated working and shared care overstep the mark and quite frankly become ‘dumping’? Recently, there has been a growing sense of frustration in primary care at the ‘GP to chase’ rhetoric, which plagues hospital discharge summaries and outpatient clinic letters. This prompted the following response on Twitter:

‘Hospital docs please, respectfully etc, note difference between GP and labrador’.

It feels like one-way traffic in general practice, but the truth is that our hospital colleagues feel equally dumped on by us. I can certainly hold my hands up and say that there have been times when I have been unable to handle the uncertainty and I have fired off a half-hearted referral, just to ease the pressure and share the load. I wouldn’t for a second blame the doctor at the receiving end for bemoaning my actions. The sad reality is that despite all the gatekeeping we do in general practice, we sometimes get it wrong and make ‘inappropriate’ referrals; when hospital wards and clinics are bursting at the seams, its unsurprising that this is greeted with great dissatisfaction. It seems as though, whilst we are sinking, we get unhelpfully defensive and look to point the finger at each another. It sometimes feels as though we purposely close our eyes to each others’ plight, just as a means of survival.

So how do we join forces on the battleground? It may sound simplistic but perhaps we need to spend more time in each others kingdoms. At the very least it would engrain reasonable expectations of what the other can do. As GPs we gain invaluable experience of hospital medicine during our training years. On the other hand, there are specialists who have never set foot in general practice, beyond undergraduate level training. This leads to misunderstandings about workload and archaic views of what GPs do. As professionals, we stand to gain a lot by coming together. Namely, respect and understanding. But if we truly succeed in breaking down institutional divides, it will be our patients who reap the benefits of holistic interdisciplinary care.

Collaborative working is of growing importance in the face of an ageing population and rising multi-morbidity, but the way in which we practice now just doesn’t allow for it. In recent years our focus in primary care has been on improving access, but some speculate as to whether this has just perpetuated spiralling demand. Every day, minor ailments walk through my door that would have resolved without any input from a GP. I sometimes feel as though we are seeing more and more patients at the expense of providing holistic and coordinated care for those who most need it. It is clear that we need to to invest in the primary care-secondary care interface for the sake of these patients, but what can we safely stop doing in order to make this happen?

Join us for the @GPJournalclub discussion at 8pm on the 8th May to discuss this paper and to explore the primary care–secondary care interface in more depth.

Feel free to leave suggestions for questions on the night – tweet me @RammyaMathew, or leave a reply in the comments box.

Bridging the gaps in care: are charities the way forward?

Ashika Sequeira (top right), Vanessa Oo (lower right) and Alexandra Grove (left)

Ashika Sequeira (top right), Vanessa Oo (lower right) and Alexandra Grove (left)

Ashika Sequeira trained on the Bromley GP Scheme and is a Locum General Practitioner. Alexandra Grove is an ST2 trainee in General Practice in the Tower Hamlets training scheme, East London. Vanessa Oo is a GPST2 in the UCLH GP training scheme.

Work can sometimes feel like a battle: a daily struggle to engage with our ever increasing list of patients and their complex co-morbidities. One of the challenges we face is a society which promotes unhealthy practices. Despite a growing awareness of the negative impact of poor diet and sedentary lifestyles on health, effective preventative care is increasingly difficult to deliver in our time-pressured consultations. Empowering our patients to proactively manage their health has never been more important in the role of a GP.

Our recent experience working with a homeless charity has opened our eyes to ways we as GPs can tackle preventative care through collaboration with community groups. Through Team Up, (an initiative bringing charities and trainee health professionals together to improve health), we worked with Single Homeless Project (SHP), a charity organisation based in North London.

Our aim was to provide the charity’s homeless clients with a simple, sustainable intervention to improve their health.

There were several challenges: the clients were difficult to engage in regular healthcare promotion and re-attendance was low. The homeless population in general has a higher incidence of medical and psychological morbidity, exacerbated by factors such as smoking, alcohol and drug abuse.1,2,3 Barriers to accessing healthcare in this population often leads to multiple presentations to A&E, a difficult and inappropriate environment for preventative care.

An extensive survey by the charity identified 70% of their clients were interested in taking part in some sort of exercise and 60% were interested in exploring their community.4

This led to the idea of a regular walking group for clients within SHP’s existing geographical sites. We decided to deliver health promotion through SHP’s existing staff to take advantage of their personal relationship with clients and to ensure the project would be sustainable. We designed an interactive session based on the theme of exercise to be delivered to SHP’s staff.

Feedback from both staff and managers was that the presentation was accessible and served to highlight the usefulness of health statistics in relating the impact of walking to a healthier lifestyle. 65% of staff felt they would not be able to discuss exercise confidently with their clients and over 87% did not know the current Department of Health recommended exercise guidelines. Following our intervention, this increased to 100% in both domains. ‘It’s easy to forget about exercise when dealing with clients who may be living in chaos, I hadn’t thought about what they might already be doing as a way of highlighting other strengths’ commented one staff member.

The momentum has continued to build. SHP walking groups have now been set up at least monthly in four London boroughs. Part of their success has been SHP enthusiastically taking over the original idea, developing their own versions, including mushroom collecting and photography walks to suit their smaller groups.  One of SHPs most encouraging comments has been that it has put exercise on the agenda for their charity.

These successes have demonstrated the power we have as health professionals to involve health as part of the conversation with charities. Charities have a wealth of experience with patients we may otherwise find difficult to engage. They provide a unique understanding of the community, can provide local links to resources and have often built up years of trusting relationships with clients.

GPs working in partnership with such community groups could provide effective prevention and health education to a much larger population than within the confines of a consulting room. Furthermore, working with a charity can be an invigorating way to flex a different part of your brain and develop a unique skill set.  It was really enriching to take on an organisational role and work with specialists from another discipline.

Of course, with primary care already at breaking point and resources thin on the ground, we are certainly not suggesting this should further overburden GPs at the expense of regular patient care. CCGs should encourage building networks between GPs and community groups and provide funding for GPs to support these groups. We would argue, in the long term, this represents a more efficient model for health promotion and providing preventative care, particularly in populations with significant barriers to access. In resource-pressured times, we need to think outside the box.  It’s time to come together with charities – for our patients, for our NHS, and even for us.

References

1. Schanzer B, Dominguez B, Shrout PE, Caton CLM. Homelessness, health status, and health care use. Am J Public Health. 2007;97:464–469
2. Chau S, Chin M, Chang J, et al. Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev. 2002;11:431–438.
3. Fischer PJ, Breakey WR. The epidemiology of alcohol, drugs, and mental disorders among homeless persons. Am Psychol. 1991;46:1115–1128.
4. Single Homeless Project, London. Available at http://www.shp.org.uk.

Hearing crackles: reflections on PACES and prejudice

Picture1Rachel Brettell is an Academic Clinical Fellow GP Trainee in the Oxford Deanery.

As a GP registrar, the MRCGP Clinical Skills Assessment (CSA) exam is currently at the forefront of my mind. VTS teaching focuses on how to pass, evenings are spent revising, and my bank account, now £1700 lighter, still makes me shudder. And yet, perhaps naively, it was still a shock to me to find out that at no point in the CSA exam am I expected to accurately detect real clinical signs. Of course, the CSA assesses many other important skills, including problem solving skills, person-centred care and attitudinal aspects. My argument is certainly not with the inclusion of these. However, given that ‘the validity of the CSA resides in its realistic simulation of real-life consultations,’ it seems strange that it includes no real patients, and consequently no real physical signs, both somewhat important components, I would argue, of many real-life consultations.

By contrast, the clinical component of Membership of the Royal College of Physicians (MRCP), the PACES exam (Practical Assessment of Clinical examination skills), involves real patients with a given condition. Candidates undertake a respiratory, abdominal, cardiovascular and neurological exam, as well as a history station, communication and ethics station, and two brief clinical consultations. In these, candidates are given eight minutes with a patient to take a focused history, carry out a relevant examination, respond to the patient’s concerns, and explain a management plan. This PACES exam is robust, and considered a rite of passage for medical trainees, who often require multiple attempts to pass. To a GP trainee it often seems unattainably tough. When colleagues pass, we congratulate them, but we also breathe a sigh of relief that we don’t have to go through the same arduous process, and in doing so, we perhaps elevate our colleagues above ourselves.

I would argue this is wrong on many levels.

This veneration of MRCP gives the impression that our exit exams are ‘easier’, or that we couldn’t pass a more robust exam should we need to. As a GP trainee who decided to undertake my MRCP exam, I would argue this is far from the truth. When I first started revising for the exam, I was met with a mix of attitudes. Confusion from many other trainees (why on earth would I put myself through such an arduous process when I didn’t have to), despair from my husband (yet another set of costly exams and weekends revising), and downright derision from my programme directors, who actively discouraged me from taking the exam as it would be a ‘distraction’ from ‘becoming a good GP’. But having been through the process, I can argue sincerely that I have little doubt I am a much better GP as a result. Revision involved seeing and examining vast numbers of patients and I now have much greater confidence in my ability to detect signs and synthesise clinical findings appropriately, quickly, and under pressure.

The two brief clinical encounters are pretty much as close to a real life GP consultation as you can get, and preparing for this was directly relevant to my day to day practice in GP. The sophisticated communication skills training I have received as a GP trainee was invaluable for the history and communication stations. The feedback I regularly receive from my GP trainers was far more meaningful and insightful than that given at expensive revision courses run by eminent hospital consultants, and is something I truly value as a result. Attending revision courses and practicing with colleagues really made me appreciate the art of consulting that we spend much time and effort honing, particularly as I watched others tying themselves up in nots over ethical dilemmas and breaking bad news scenarios that would be bread and butter to a GP trainee.

But more than just the relevance of the exam and the associated learning, gaining my MRCP has taught me so much more. It was a hard, but an eminently passable exam. Whilst it is tempting to put medical colleagues who have passed on a pedestal, this is dangerous, and risks exacerbating the disconnect between primary and secondary care. As GPs we are more than capable of passing this exam. I spend my days seeing undifferentiated patients, who present with a symptom (or 7!) rather than a diagnosis. Hence, ‘examine this patient with shortness of breath’ didn’t frighten me. I rarely have the results of bloods, imaging or other diagnostic tests on hand to confirm a diagnosis. Hence, detecting and interpreting a patient’s heart murmur without the luxury of an echo wasn’t anything new. Seeing a wide variety of patients in quick succession under considerable time pressure is ‘just another day in the office’ to me.

Furthermore, the revision process made me realise that some of our medical colleagues have an almost laughable lack of understanding of what we do, and what we face, day in day out in primary care. Whilst revising with a hospital colleague, I completed a particularly gruelling viva on pulmonary fibrosis. He was impressed with my answers (helped by a recent respiratory job), but, when he found out I was a GP trainee, exclaimed ‘What a waste! Why does a GP need to know anything about pulmonary fibrosis? You just hear the crackles and refer.’ My jaw dropped with disbelief, and had it not been so sincere, it might have been funny. He couldn’t understand the fundamental role of the GP in managing even the most complex medical patients. Needless to say I took some pleasure in pointing this out to him, but whilst silently sobbing inside.

Who suspects the initial diagnoses, and filters it out from all the others? Who supports the patient and their family through the diagnostic pathway, the treatment, and the inevitable decline? Who is there for anything and everything between their 3 monthly respiratory clinic appointments? Who keeps them out of hospital wherever possible, but negotiates an admission when needed? Who coordinates the vast array of healthcare professionals involved in their care? Of course, their GP. Yes, we value communication skills and holistic care, but we also provide very real medical care too. With foundation exposure to general practice remaining disappointingly low, we really do have a duty to address these disappointingly common misconceptions about what GPs do and the challenges we face.

Finally, and more controversially, I was met in some cases with a prejudice that I, as a GP trainee, wouldn’t be up to the rigorous exam process in a way that my medical colleagues were. The sad truth, that most aren’t willing to acknowledge, is that some secondary care colleagues still presume that people become GPs because they can’t get in to anything else. Several I spoke to were shocked that I had turned down a core medical job to undertake GP training. Most underestimated just how passionately we believe in the crucial role that GPs play, the enormous difference we can make to patient care, and the excellence we can strive to achieve as true generalists. It surprised many that I could be bothered to learn for an exam that wasn’t compulsory – a far cry from the reality of my cohort of GP trainees who have voluntarily undertaken (and paid for) many extra qualifications to further their knowledge and expertise. It gave me some pleasure when these types saw me perform well on a particular station, but that pleasure was far outweighed by the disappointment that this arrogance and lack of respect can still persist within our profession.

However, I believe it is just as much our job to get out there and change these attitudes and to prove our worth, as it is for our hospital colleagues to start recognising and respecting our skills. We still work in a hierarchical system of long held beliefs and prejudices. Until MRCGP is looked on with the same reverence as MRCP, we have work to do. I refuse to be looked down on by colleagues and our exit exam, which seemingly places little emphasis on detecting clinical signs, may actually play into many prejudices about the profession, as a touchy feeling world where failed medics go to see out their days trying to persuade patients with viral URTIs they really don’t need antibiotics and managing mild depression.

So I would argue, perhaps only a little tongue in cheek, we all should be taking PACES. I think back to my revision course colleague and his belief that, as GPs, we ‘hear crackles and refer.’ Passing this exam means yes, I hear the crackles and have confidence in my ability to do so. But, perhaps most importantly of all, just one or two more of my hospital colleagues might also now recognise and value us GPs as the robust, efficient and highly skilled clinical workforce we are, who do so much more than ‘just hear crackles and refer…’

GP Journal Club – April 2016

The April GP Journal Club is now on Storify.

The paper discussed was: Lorgeril M, Rabaeus M. Beyond confusion and controversy, can we evaluate the real efficacy and safety of cholesterol-lowering with statins? JCBMR 2016;1(1):67

The next GP Journal Club will be in May – you can follow @GPjournalclub and #gpjc on Twitter. Click here for the GP Journal club blogposts.

GP Journal Club – Sunday 10th April at 8pm

image1The next GP Journal Club will be discussing the paper: Lorgeril M, Rabaeus M. Beyond confusion and controversy, can we evaluate the real efficacy and safety of cholesterol-lowering with statins? JCBMR 2016;1(1):67

You can download it here.

Angharad Powell is a Portfolio GP based in North Wales, working in a salaried role, as a tribunal doctor, and as a GP appraiser.

Statins – where next?

Prescribing statins has become a daily part of life for GPs. Early statin trials, such as 4S and WOSCOPS, appeared to demonstrate dramatic and conclusive benefits for statins over placebo, leading to their recommendation for a rising percentage of the population.1,2 Over recent years the waters have muddied with regard to the safety and efficacy of these drugs, with increasing controversy about the quality of the evidence base, and validity of the diet-heart hypothesis.3

Since 2014 NICE has recommend that GPs offer atorvastatin 20 mg for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD.4 These new guidelines have received a mixed reaction among doctors and researchers, uncertain as to whether the benefits outweigh the risks, as evidence emerges of previously unrecognised effects such as doubling of diabetes risk.5

The 2013 clash between Sir Rory Collins and Fiona Godlee, editor of the BMJ on the publication of an article suggesting that 18-20% of patients on statins suffer side effects brought many of the problems with statin trial evidence to light.More recently Dr Aseem Malhotra, a prominent cardiologist, also highlighted the discrepancy between side effects reported in industry sponsored trials and real world experience, calling for a full reassessment of all the statin studies.7

As doctors prescribing drugs to healthy people with the promise that they may prevent an unwanted outcome, we must be very sure that we are following our moral duty to “first do no harm”. The uncertainties raised by these analyses raise the possibility that we are not currently meeting that obligation. We risk the trust of out patients if we do not take a step back and take a critical look at the evidence base to determine the appropriate place of statins in our practice.

This paper by Michel de Lorgeril and Mikael Rabaeus provides a challenge to the current viewpoint, and I hope will provide the foundation for a lively debate on the topic.8

Proposed questions:

·What do you think about the study design?

·Do you agree that the “entire ecosystem of drug evaluation and regulation could be flawed”?

·Comments on the authors’ conclusion that “physicians should be aware that the present claims about the efficacy and safety of statins are not evidence based.”

Feel free to suggest questions – via Twitter or leave them in the comments box below.

References:

1. The Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 people with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383–9.

2. Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998;339:1349–57.

3. Ioannidis JA. More Than a Billion People Taking Statins? Potential Implications of the New Cardiovascular Guidelines. JAMA 2014;311(5):463-464. doi:10.1001/jama.2013.284657.

4. Cardiovascular disease prevention | Guidance and guidelines | NICE [Internet]. Nice.org.uk. 2010 [cited 6 April 2016]. Available from: https://www.nice.org.uk/guidance/ph25

5. Mansi I, Frei C, Wang C, Mortensen E. Statins and New-Onset Diabetes Mellitus and Diabetic Complications: A Retrospective Cohort Study of US Healthy Adults. J Gen Intern Med. 2015;30(11):1599-1610.

6. Independent statins review panel | The BMJ [Internet]. Bmj.com. 2016 [cited 6 April 2016]. Available from: http://www.bmj.com/about-bmj/independent-statins-review-panel

7. The Great Statin Con? [Internet]. The Huffington Post UK. 2016 [cited 6 April 2016]. Available from: http://www.huffingtonpost.co.uk/dr-aseem-malhotra/great-statin-con_b_9607316.html

8. Lorgeril M, Rabaeus M. Beyond confusion and controversy, can we evaluate the real efficacy and safety of cholesterol-lowering with statins? JCBMR 2016;1(1):67.

Yonder: Rosacea, youth mental health, diagnosing arthritis and telephone triage

F1.largeAhmed Rashid is an academic clinical fellow in general practice at the University of Cambridge. He writes the regular monthly column “Yonder” in the BJGP: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature. Twitter: @Dr_A_Rashid

You can download the PDF here at BJGP.org.

Rosacea
Rosacea is a common, chronic skin condition in adults. As it predominantly affects the face, it has the potential to cause significant psychological and social distress. The internet has provided opportunities for patients to access information as well as interact with peers and experts. A US research team recently analysed posts on an online rosacea support forum to obtain insights into patients’ educational needs.1 They found that patients primarily sought advice about treatments, triggers, diet, and skin care. Perhaps unsurprisingly, there were also a large number of queries about the efficacy and adverse effects of therapies.

The authors suggest that doctors should make more attempts to include patients in their rosacea care and suggest that one way of doing this is to have them take pictures to track progress and keep a diary of potential triggers. They also suggest that proactively providing resources could help reduce confusion about the disease and treatments.

Youth mental health
Youth mental health is increasingly recognised as a priority area in health systems around the world. In particular, there has recently been an increased focus on early intervention and an Irish research team recently sought to examine the role of the GP in providing early treatment in this population.2

They combined a national survey of GPs with interviews of both health professionals and young people. They found that GPs were largely unsatisfied with their postgraduate training in child mental health and substance misuse. Access to services and youth workers were cited as key facilitators to improve care. Much like in the NHS, it seems an increase in funding for mental health services is also acutely needed in the Irish health system.

Diagnosing arthritis
Progress in rheumatoid arthritis management in recent years has meant that starting treatment early is more important than ever. However, this naturally relies on early identification and a Dutch rheumatology team recently examined the signs, symptoms, and investigations that GPs use in the diagnosis of inflammatory arthritis, analysing medical records.3 They used records from 16 practices and found 126 patients with new diagnoses of inflammatory arthritis. Information about classic inflammatory symptoms (pain, swelling, warmth, redness, reduced function) was frequently documented but items that they record as being routinely checked in secondary care (morning stiffness, family history and squeeze-test) were rarely used. In the UK, the increasing use of referral proformas with checklists may already have mostly ameliorated this issue.

Telephone triage
Practices are increasingly using telephone triage to manage patient flow but there are many unanswered questions about its effectiveness and safety. In the Netherlands, telephone triage in the daytime is done by practice assistants who generally have followed an intermediate vocational medical education of 3 years. A recent Dutch study sought to examine the adequacy of this triage, conducting a web-based survey asking practice assistants to assess the required type of care of written case scenarios with varying health problems and levels of urgency.4 They found that the required care was assessed adequately in 63.6% of cases, was over-estimated in 19.3%, and under-estimated in 17.1% and predictably, more experienced assistants and assistants with fixed daily work meetings with the GP performed better.

The authors conclude that telephone triage by general practice assistants is efficient, but potentially unsafe in highly urgent cases and suggest improved training is the key solution. As for NHS general practice, it seems increasingly likely that there will be more multidisciplinary working in years to come and this paper provides some insights into the kind of challenges (and opportunities) this may bring.

REFERENCES
1. Alinia  H, Moradi Tuchayi  S, Farhangian  ME, et al. (2016) Rosacea patients seeking advice: Qualitative analysis of patients’ posts on a rosacea support forum. J Dermatolog Treat 27(2):99–102.

2. Leahy  D, Schaffalitzky  E, Saunders  J, et al. (2015) Role of the general practitioner in providing early intervention for youth mental health: a mixed methods investigation. Early Interv Psychiatry doi:10.1111/eip.12303.

3. Newsum  EC, de Waal  MW, van Steenbergen  HW, et al. (2016) How do general practitioners identify inflammatory arthritis? A cohort analysis of Dutch general practitioner electronic medical records. Rheumatology (Oxford) pii:kev432.

4. Smits  M, Hanssen  S, Huibers  L, Giesen  P (2016) Telephone triage in general practices: A written case scenario study in the Netherlands. Scand J Prim Health Care 19:1–10.

Zika virus testing: practical management for primary care

PhotoCMousoulis

Dr Mousoulis

PhotoBSibal

Dr Sibal

Christos Mousoulis is a medical doctor specialising in Public Health. He is currently an Academic Clinical Fellow doing his health protection placement at Public Health England – West Midlands East team. His main interest is in Academic Public Health and in Clinical Trials in particular.

Bharat Sibal is a Lead Consultant in Communicable Disease Control working for Public Health England, Health Protection Team based in Birmingham. He has worked for WHO in Nepal and India and has wide interests in control of infectious diseases internationally.

Over the last few months a lot of media attention has being put on Zika virus and various national guidance has been produced. As Public Health England (PHE) Health Protection Team we have received a number of queries from GPs and other primary care colleagues regarding Zika virus testing and the role of diagnostics in primary care. PHE has produced various guidance on Zika virus and a specific one has been produced for primary care.1 We also read the article published in BJGP2 with interest and based on current guidance from PHE we believe that the following should be helpful to resolve queries from our primary care colleagues. Please note that these recommendations are being updated periodically to reflect up-to-date evidence which is available at: https://www.gov.uk/guidance/zika-virus.3

What is the test for Zika?
A blood test can confirm or exclude the presence of Zika virus in symptomatic patients only. Main symptoms are fever, headache, rash, joint pain and muscle pain. A clotted ‘red top’ (plain) or ‘yellow top’ (serum separator) blood, EDTA ‘purple top’ blood and a small volume of urine without preservative should be sent to the local microbiology/virology laboratory.1 The attending clinician should complete a standard, local laboratory form along with PHE – Rare and Imported Pathogens Laboratory request form (RIPL) available at: https://www.gov.uk/government/publications/rare-and-imported-pathogens-testing-form-to-submit-sample.1 The blood test is then sent to be processed by the RIPL. Travel history and clinical details should also be included on the form. The blood test is a PCR test, i.e. it tests for the presence of DNA of the virus in symptomatic patients only. It can only detect Zika virus during a seven day period following the onset of symptoms. It is not an antibody test, so it cannot confirm or exclude prior infection. RIPL is in the process of developing a prototype antibody test for Zika, but this is not yet widely available.

Who should be tested?
A pregnant woman with a history of travel to a Zika area during pregnancy, who reports clinical illness that raises the suspicion of Zika virus disease, during or within 2 weeks of travel, should be tested for Zika virus infection.4

All other pregnant women who have travelled to a Zika area during pregnancy should have a blood test done which will be stored.4 Please do not forget that all pregnant women who have travelled should also have a baseline ultrasound scan. Non-pregnant individuals who present with active symptoms suggestive of Zika infection should have the blood test as well. However, non-pregnant patients who were diagnosed elsewhere and who have recovered from their infection do not require further investigation and can be reassured that Zika infection is short-lived and self-resolving.5

What if the result is positive?
If a pregnant woman has a positive test she should be referred to the local specialist Fetal Medicine Unit.4 If there is evidence of a problem with a baby (e.g. found on ultrasound scan) from a woman who has or who may have been diagnosed with Zika, the RIPL can test amniotic fluid for the virus. This will only be the case if the patient and the clinical team accept the risk of amniocentesis and the option of therapeutic termination of the pregnancy for a positive result.4 If someone has been diagnosed with the virus, this does not necessarily mean that the virus has affected the baby. They will be cared for and monitored throughout the pregnancy by the Fetal Medicine Unit and their midwife.

References

1 Public Health England. Zika virus infection: guidance for primary care (4th February 2016) URL: https://www.gov.uk/government/publications/zika-virus-infection-guidance-for-primary-care [23rd March 2016]

2 Burke RM, Pandya P, Nastouli E, Gothard P. Zika virus infection during pregnancy: what, where and why? Br J Gen Pract 2016; 66 (644): 122-123

3 Public Health England. Health protection – guidance. Zika virus (17th March 2016) URL: https://www.gov.uk/guidance/zika-virus [23rd March 2016]

4 Royal College of Obstetricians and Gynaecologists. Interim clinical guidelines on Zika virus infection and pregnancy (29th January 2016) URL: https://www.rcog.org.uk/en/news/interim-clinical-guidelines-on-zika-virus-infection-and-pregnancy/ [23rd March 2016]

5 National Travel Health Network and Centre (NaTHNaC). Travel Health Pro (17th March 2016). URL: http://travelhealthpro.org.uk/diseases/zikavirus/ [23rd March 2016]