RATs: Quality not Quantity


The British Journal of General Practice is an international journal publishing research, debate and analysis, and clinical guidance for family practitioners and primary care researchers worldwide. The BJGP Blog brings opinion to research and clinical practice.

image1Joe Anthony is a history graduate currently in his fourth year studying medicine at the University of Manchester. He was joint second in the BJGP Student Writing Competition which had the theme The GP in the Digital Age. Joe’s article took us straight into how technology has an impact on two key topics for any GP: quality and continuity.

Talk to any politician and they will tell you that the problem is one of access. ‘GPs should be working 7 days a week’, ‘more appointment-slots should be available’, ‘better access equals a better service’, they yell from their soapboxes. And with a growing population, which has ever-increasing expectations of what the NHS should do for them, you might be forgiven for thinking that the problem is simply one of quantity.

This attitude is evident in the government’s recent approach to improving general practice. Development of effective telehealth in the UK has been a priority, with CCGs rolling out these services thanks to heavy financial backing. Telephone consultations were once the purported solution; increasing ease of access and therefore the quantity of consultations available was the goal, however, the results were far from satisfactory as the increased access simply led to greater demand. The telephone slots were used but those same patients too often still required a traditional consultation, hence the ESTEEM trial’s conclusion that telephone consultations were not cost-effective.1

CCGs are therefore turning to the next step in telecommunications and video consultations using Skype are now widely available. These continued attempts to pursue telehealth seem to ignore the lessons learnt on the telephone. Telehealth provides consultations at the click of a button, day or night, decreasing overheads for premises, administration staff, and the like. The goal is an increased number of consultations at low cost but as these services are not proving economical and have not tackled the previous issue of patients requiring a repeated consultation, what purpose do they serve?2

The digital age is, however, supplying technologies that are resulting in palpable improvements to health services. While telehealth receives the headlines and funding, the comparatively humdrum integration of Risk Assessment Tools (RATs) is leading to faster and safer consultations. In broad terms, this utilisation of software to carry out important analysis of patient data can and does save GPs valuable time, which can be better spent elsewhere in the consultation.

The growing numbers of RATs available to GPs are small steps that can make a big difference to patients. ECLIPSE (Education & Cost-analysis Leading to Improved Prescribing Safety & Efficiency) is just one example of such a tool. The software analyses data on practice systems and uses algorithms to detect long-term trends in clinical entries, prescribing, and pathology results. ECLIPSE identifies patients who are overdue for monitoring tests or being put at risk by their medications and presents these findings via a traffic light system of alerts, with the aim being to prevent unnecessary hospitalisations. For example, a full blood count shows a haemoglobin of 13.5 g/dL, a rushed GP sees a normal result but ECLIPSE sees the bigger picture. This patient is on an NSAID and their haemoglobin was 16.0 g/dL 2 months ago, an ODG is ordered, a peptic ulcer is detected, and an outcome improved.

ECLIPSE has already been rolled out by several CCGs and more RATs are being added; for example, Nottingham’s QCancer® score and Professor Willie Hamilton’s cancer prediction tools which aim to tackle an identified weakness of the NHS — early cancer diagnosis.3,4 This is not the story of a digital panacea, rather of incremental improvements that have the potential to improve general practice, and thus patient outcomes.

Talk to any GP and they will tell you the problem is not one of access. They will tell you the focus should not be on quantity but on quality. They will emphasise the importance of continuity of care and a safe and efficient service. RATs are helping to provide that service.


1. Campbell JL, Fletcher E, Britten N, et al. (2014) Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis. Lancet 384(9957):1859–1868.

2. Henderson C, Knapp M, Fernandez JL, et al. (2013) Cost effectiveness of telehealth for patients with long term conditions (Whole Systems Demonstrator telehealth questionnaire study): nested economic evaluation in a pragmatic, cluster randomised controlled trial. BMJ 346:f1035.

3. Rubin G, Vedsted P, Emery J (2011) Improving cancer outcomes: better access to diagnostics in primary care could be critical. Br J Gen Pract doi:10.3399/bjgp11X572283.

4. Hamilton W, Green T, Martins T, et al. (2013) Evaluation of risk assessment tools for suspected cancer in general practice: a cohort study. Br J Gen Pract doi:10.3399/bjgp13X660751.

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