General Practices In England Research Articles

Prevalence of Comorbid Mental and Physical Illnesses and Risks for Self-Harm and Premature Death Among Primary Care Patients Diagnosed with Fatigue Syndromes

Background: Fatigue syndromes affect large numbers of individuals, yet evidence from epidemiological studies on adverse outcomes, such as premature death, is limited. Methods: Cohort study involving 385 general practices in England that contributed to the Clinical Practice Research Datalink (CPRD) with linked inpatient Hospital Episode Statistics (HES) and Office for National Statistics (ONS) cause of death information. A total of 10,477 patients aged 15 years and above, diagnosed with a fatigue syndrome during 2000-2014, were individually matched with up to 20 comparator patients without history of having a fatigue syndrome. Prevalence ratios (PRs) were estimated to compare the fatigue syndrome and comparison cohorts on clinical characteristics. Adjusted hazard ratios (HRs) for subsequent adverse outcomes were estimated from stratified Cox regression models. Outcomes: Among patients diagnosed with fatigue syndromes, we found elevated baseline prevalence of: any psychiatric illness (PR 1.77; 95% CI 1.72-1.82), anxiety disorders (PR 1.92; 1.85-1.99), depression (PR 1.89; 1.83-1.96), psychotropic prescriptions (PR 1.68; 1.64-1.72), and comorbid physical illness (PR 1.28; 1.23-1.32). We found no significant differences in risks for: all-cause mortality (HR 0.99; 0.91-1.09), natural death (HR 0.99; 0.90-1.09), unnatural death (HR 1.00; 0.59-1.72), or suicide (HR 1.68; 0.78-3.63). We did, however, observe a significantly elevated non-fatal self-harm risk: HR 1.83; 1.56-2.15. Interpretation: The absence of elevated premature mortality risk is reassuring. The raised prevalence of mental illness and increased non-fatal self-harm risk indicate a need for enhanced assessment and management of psychopathology associated with fatigue syndromes. Funding: NIHR Greater Manchester Patient Safety Translational Research Centre. Conflict of interest statement: PDW is a member of the Independent Medical Experts Group; an advisory non-departmental public body, which advises the UK Ministry of Defence regarding the Armed Forces Compensation Scheme. In the past, PDW has provided unpaid advice to the UK Department for Work and Pensions regarding mental health issues. PDW does paid consultancy work for a re-insurance company. NK is supported by Greater Manchester Mental Health and Social Care Trust. NK chaired the guideline development group for the 2012 NICE guidelines on the longer term management of self-harm and currently chairs the guideline development group for the NICE depression in adults guideline. NK is also a member of the Suicide Prevention Advisory Group at the Department of Health. Ethical Approval Statement: The study was approved by the independent scientific advisory committee (ISAC) for Clinical Practice Research Datalink research (protocol number: 16_050R).

Importance of accessibility and opening hours to overall patient experience of general practice: analysis of repeated cross-sectional data from a national patient survey.

The UK government aims to improve the accessibility of general practices in England, particularly by extending opening hours in the evenings and at weekends. It is unclear how important these factors are to patients' overall experiences of general practice. To examine associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours. Analysis of repeated cross-sectional data from the General Practice Patient Surveys conducted from 2011-2012 until 2013-2014. These covered 8289 general practice surgeries in England. Data from a national survey conducted three times over consecutive years were analysed. The outcome measure was overall experience, rated on a five-level interval scale. Associations were estimated as standardised regression coefficients, adjusted for responder characteristics and clustering within practices using multilevel linear regression. In total, there were 2 912 535 responders from all practices in England (n = 8289). Experience of making appointments (β 0.24, 95% confidence interval [CI] = 0.24 to 0.25) and satisfaction with opening hours (β 0.15, 95% CI = 0.15 to 0.16) were modestly associated with overall experience. Overall experience was most strongly associated with GP interpersonal quality of care (β 0.34, 95% CI = 0.34 to 0.35) and receptionist helpfulness was positively associated with overall experience (β 0.16, 95% CI = 0.16 to 0.17). Other patient experience measures had minimal associations (β≤0.06). Models explained ≥90% of variation in overall experience between practices. Patient experience of making appointments and satisfaction with opening hours were only modestly associated with overall experience. Policymakers in England should not assume that recent policies to improve access will result in large improvements in patients' overall experience of general practice.

Emollient expenditure: time to scratch a budgetary itch

Emollient expenditure: time to scratch a budgetary itch

Inequalities in zoster disease burden: a population-based cohort study to identify social determinants using linked data from the U.K. Clinical Practice Research Datalink

This study, from a team working at the London School of Hygiene and Tropical Medicine in the UK, investigated a large group of patients aged 65 or over, seeing a GP between 2003 and 2013 who had experienced an attack of shingles (herpes zoster) during this period. The source of the information was an anonymised data base known as the Clinical Practice Research Data link which records information from many general practices in England. The data was obtained before the introduction of the zoster (shingles) vaccine in the UK. Amongst over 37,000 patients with shingles there was a higher rate of infection in those living in care homes, in females and in non‐migrants or in those with white ethnicity as well as those living alone. There were slightly fewer cases of shingles in those living in deprived circumstances. Although patients taking treatments that reduced the overall level of immunity were more likely to develop shingles, diabetic patients were not. The authors suggest that it might be helpful to promote immunization in some of these groups, such as those living in care homes.

Factors associated with consultation rates in general practice in England, 2013-2014: a cross-sectional study.

BackgroundWorkload in general practice has risen during the last decade, but the factors associated with this increase are unclear.AimTo examine factors associated with consultation rates in general practice.Design and settingA cross-sectional study examining a sample of 304 937 patients registered at 316 English practices between 2013 and 2014, drawn from the Clinical Practice Research Datalink.MethodAge, sex, ethnicity, smoking status, and deprivation measures were linked with practice-level data on staffing, rurality, training practice status, and Quality and Outcomes Framework performance. Multilevel analyses of patient consultation rates were conducted.ResultsConsultations were grouped into three types: all (GP or nurse), GP, and nurse. Non-smokers consulted less than current smokers (all: rate ratio [RR] = 0.88, 95% CI = 0.87 to 0.89; GP: RR = 0.88, 95% CI = 0.87 to 0.89; nurse: RR = 0.91, 95% CI = 0.90 to 0.92). Consultation rates were higher for those in the most deprived quintile compared with the least deprived quintile (all: RR = 1.18, 95% CI = 1.16 to 1.19; GP: RR = 1.17, 95% CI = 1.15 to 1.19; nurse: RR = 1.13, 95% CI = 1.11 to 1.15). For all three consultation types, consultation rates increased with age and female sex, and varied by ethnicity. Rates in practices with >8 and ≤19 full-time equivalent (FTE) GPs were higher compared with those with ≤2 FTE GPs (all: RR = 1.26, 95% CI = 1.06 to 1.49; GP: RR = 1.36, 95% CI = 1.19 to 1.56).ConclusionThe analyses show consistent trends in factors related to consultation rates in general practice across three types of consultation. These data can be used to inform the development of more sophisticated staffing models, and resource allocation formulae.

The pattern of prescribing of glucose modulating agents for type 2 diabetes in general practices in England 2016/17.

In the financial year 2016/17 there were 52.0 million items prescribed for diabetes at a total net ingredient cost of £983.7 million - up from 28.9 million prescription items and £572.4 million in 2006/07. Anti-diabetes drugs (British National Formulary section 6.1.2) make up 45.1 per cent of the total £983.7 million net ingredient cost of drugs used in diabetes and account for 72.0 per cent of prescription items for all diabetes prescribing. We examined the way that agents licensed to treat type 2 diabetes were used across GP practices in England in the year 2016/2017. Analysis was at a GP practice level not at the level of patient data. Annual prescribing costs / patient / medication type for monotherapy varied considerable from £11/year for gliclazide and glimepiride to £885/year for Liraglutide. The use of SGLT-2i agents grew strongly at 70% per annum to around 100,000 DDD with prescriptions seen in 95% of GP practices. Liraglutide expenditure (11% of total) was high for a relatively small number of patients (1.3% of Defined Daily Doses), with still significant spend on exenatide. Liraglutide use significantly exceeded that of other glucagon-like peptide-1 (GLP-1) agonists. Our work demonstrates the significant cost of medication to modulate tissue glucose levels in type 2 diabetes and the dominance of some non-generic preparations in terms of number of prescriptions and overall spend. There are some older sulphonylureas in use, which should not generally be prescribed. Regular audit of patient treatment at a general practice level will ensure appropriate targeted use of licensed medications and of their cost effectiveness.

Regional variation and predictors of over-registration in English primary care in 2014: a spatial analysis

BackgroundThere are more people registered with a general practice in England than are estimated to be resident in the country. The reasons behind this are not fully understood. We investigated...

The impact of new forms of large-scale general practice provider collaborations on England's NHS: a systematic review.

Over the past decade, collaboration between general practices in England to form new provider networks and large-scale organisations has been driven largely by grassroots action among GPs. However, it is now being increasingly advocated for by national policymakers. Expectations of what scaling up general practice in England will achieve are significant. To review the evidence of the impact of new forms of large-scale general practice provider collaborations in England. Systematic review. Embase, MEDLINE, Health Management Information Consortium, and Social Sciences Citation Index were searched for studies reporting the impact on clinical processes and outcomes, patient experience, workforce satisfaction, or costs of new forms of provider collaborations between general practices in England. A total of 1782 publications were screened. Five studies met the inclusion criteria and four examined the same general practice networks, limiting generalisability. Substantial financial investment was required to establish the networks and the associated interventions that were targeted at four clinical areas. Quality improvements were achieved through standardised processes, incentives at network level, information technology-enabled performance dashboards, and local network management. The fifth study of a large-scale multisite general practice organisation showed that it may be better placed to implement safety and quality processes than conventional practices. However, unintended consequences may arise, such as perceptions of disenfranchisement among staff and reductions in continuity of care. Good-quality evidence of the impacts of scaling up general practice provider organisations in England is scarce. As more general practice collaborations emerge, evaluation of their impacts will be important to understand which work, in which settings, how, and why.

Antimicrobial prescribing in post-graduate training practices: a cross-sectional study of prescribing data in general practices in England

IntroductionSeventy-five percent of all antimicrobials are prescribed in primary care. There is a growing concern about inappropriate oral antimicrobial prescribing. Interventions to enhance antimicrobial stewardship are actively promoted through educational and other means. GP training practice status has been shown to influence patient care. This study seeks to study the influence of GP training practice status on antimicrobial prescribing.MethodsA cross-sectional analysis of practice antimicrobial prescribing data was conducted for the year 2015–2016 comparing training and non-training practices across England. Data for all practices and prescribing was obtained from NHS Digital. Univariate analyses were conducted on the two measures of antibiotic prescribing included in the study. Multivariable regression models were constructed to identify the predictors of antibiotic prescribing volumes and of broad spectrum antibiotic prescribing.ResultsGP training practice status was a significant predictor of overall antibiotic prescribing volume, B = −0.009 (95% confidence intervals, −0.012, −0.005), p < 0.001. GP training practices prescribed fewer antibiotics, representing a reduction of 6.2 centiles from the median. GP training practice status was also a significant predictor of broad spectrum antibiotic prescribing, B = −0.3 (95% confidence intervals, −0.04, −0.01), p = 0.001. GP training practices prescribed fewer broad spectrum antibiotics, representing a reduction from the median of 6.0 centiles.DiscussionTraining practices prescribe fewer antimicrobials overall and specifically fewer broad spectrum oral antimicrobials (quinolones and cephalosporins). There is a need for further research to understand the interplay between postgraduate GP training and reductions in antimicrobial prescribing.

What gives rise to clinician gut feeling, its influence on management decisions and its prognostic value for children with RTI in primary care: a prospective cohort study

BackgroundThe objectives were to identify 1) the clinician and child characteristics associated with; 2) clinical management decisions following from, and; 3) the prognostic value of; a clinician’s ‘gut feeling something is wrong’ for children presenting to primary care with acute cough and respiratory tract infection (RTI).MethodsMulticentre prospective cohort study where 518 primary care clinicians across 244 general practices in England assessed 8394 children aged ≥3 months and < 16 years for acute cough and RTI. The main outcome measures were: Self-reported clinician ‘gut feeling’; clinician management decisions (antibiotic prescribing, referral for acute admission); and child’s prognosis (reconsultation with evidence of illness deterioration, hospital admission in the 30 days following recruitment).ResultsClinician years since qualification, parent reported symptoms (illness severity score ≥ 7/10, severe fever < 24 h, low energy, shortness of breath) and clinical examination findings (crackles/ crepitations on chest auscultation, recession, pallor, bronchial breathing, wheeze, temperature ≥ 37.8 °C, tachypnoea and inflamed pharynx) independently contributed towards a clinician ‘gut feeling that something was wrong’. ‘Gut feeling’ was independently associated with increased antibiotic prescribing and referral for secondary care assessment. After adjustment for other associated factors, gut feeling was not associated with reconsultations or hospital admissions.ConclusionsClinicians were more likely to report a gut feeling something is wrong, when they were more experienced or when children were more unwell. Gut feeling is independently and strongly associated with antibiotic prescribing and referral to secondary care, but not with two indicators of poor child health.

A nurse-led cervical screening clinic in primary care.

Eliza is a practice nurse in a large general practice in England. She is trained in cancer screening and health promotion as well as chronic disease management. Today patients are consulting with her for their cervical smear test.

Meningococcal vaccination in primary care amongst adolescents in North West England: an ecological study investigating associations with general practice characteristics.

In 2015 the meningococcal ACWY (MenACWY) vaccination was introduced amongst adolescents in England following increased incidence and mortality associated with meningococcal group W. MenACWY vaccination uptake data for 17-18 years old and students delivered in primary care were obtained for 20 National Health Service clinical commissioning groups (CCGs) via the ImmForm vaccination system. Data on general practice characteristics, encompassing demographics and patient satisfaction variables, were extracted from the National General Practice Profiles resource. Univariable analysis of the associations between practice characteristics and vaccination was performed, followed by multivariable negative binomial regression. Data were utilized from 587 general practices, accounting for ~8% of all general practices in England. MenACWY vaccination uptake varied from 20.8% to 46.8% across the CCGs evaluated. Upon multivariable regression, vaccination uptake increased with increasing percentage of patients from ethnic minorities, increasing percentage of patients aged 15-24 years, increasing percentage of patients that would recommend their practice and total Quality and Outcomes Framework achievement for the practice. Conversely, vaccination uptake decreased with increasing deprivation. This study has identified several factors independently associated with MenACWY vaccination in primary care. These findings will enable a targeted approach to improve general practice-level vaccination uptake.

Managing cardiovascular disease risk in patients with severe mental illness

Managing cardiovascular disease risk in patients with severe mental illness

Adding the past to the policy mix: an historical approach to the issue of access to general practice in England

Historical perspectives can be embedded into policy initiatives through a process of ‘past-proofing’—ensuring new policies take the study of the past into consideration. We describe how this was done in a project looking at patient access to general practice in the NHS. We argue that current preoccupations with timeliness which have led to the marginalisation of other dimensions of access are connected to a broader process of neo-liberal reform since the 1970s. This reflection can support a reframing of the terms of current debates on a major issue in British health care. It has wider implications for the policy relevance of history.

Cost-effectiveness of personal tailored risk information and taster sessions to increase the uptake of the NHS stop smoking services: the Start2quit randomized controlled trial.

AimsTo assess the cost‐effectiveness of a two‐component intervention designed to increase attendance at the NHS Stop Smoking Services (SSSs) in England.DesignCost‐effectiveness analysis alongside a randomized controlled trial (Start2quit).SettingNHS SSS and general practices in England.ParticipantsThe study comprised 4384 smokers aged 16 years or more identified from medical records in 99 participating practices, who were motivated to quit and had not attended the SSS in the previous 12 months.Intervention and comparatorIntervention was a personalized and tailored letter sent from the general practitioner (GP) and a personal invitation and appointment to attend a taster session providing information about SSS. Control was a standard generic letter from the GP advertising SSS and asking smokers to contact the service to make an appointment.MeasurementsCosts measured from an NHS/personal social services perspective, estimated health gains in quality‐adjusted life‐years (QALYs) measured with EQ‐5D and incremental cost per QALY gained during both 6 months and a life‐time horizon.FindingsDuring the trial period, the adjusted mean difference in costs was £92 [95% confidence interval (CI) = –£32 to –£216) and the adjusted mean difference in QALY gains was 0.002 (95% CI = –0.001 to 0.004). This generates an incremental cost per QALY gained of £59 401. The probability that the tailored letter and taster session is more cost‐effective than the generic letter at 6 months is never above 50%. In contrast, the discounted life‐time health‐care cost was lower in the intervention group, while the life‐time QALY gains were significantly higher. The probability that the intervention is more cost‐effective is more than 83% using a £20 000–30 000 per QALY‐gained decision‐making threshold.ConclusionsAn intervention designed to increase attendance at the NHS Stop Smoking Services (tailored letter and taster session in the services) appears less likely to be cost‐effective than a generic letter in the short term, but is likely to become more cost‐effective than the generic letter during the long term.

A nurse-led review of a child with asthma.

Eliza is a practice nurse working in a large general practice in England. She is a trained nurse with additional qualifications in chronic disease management, and is also a registered prescriber. This means she can initiate or repeat medical prescriptions. Today Eliza is reviewing her asthma patients.

Development and validation of QDiabetes-2018 risk prediction algorithm to estimate future risk of type 2 diabetes: cohort study

Objectives To derive and validate updated QDiabetes-2018 prediction algorithms to estimate the 10 year risk of type 2 diabetes in men and women, taking account of potential new risk factors,...

Impact of a national diabetes risk assessment and screening programme in England: a quasi-experimental study

BackgroundThe global prevalence of type 2 diabetes is increasing but the effectiveness of large-scale screening programmes to detect high-risk individuals (eg, those with non-diabetic hyperglycaemia) is debated. We assessed the impact of a national diabetes risk assessment and screening programme, NHS Health Checks, on detection of incident cases of non-diabetic hyperglycaemia and type 2 diabetes and on management of cardiovascular risk factors in newly diagnosed cases. MethodsIn a quasi-experimental propensity score adjusted study, we extracted data on 370 454 individuals aged 40–74 years registered with 455 general practices in England between 2009 and 2016 without pre-existing type 2 diabetes. Individuals were characterised into three groups on the basis of their general practice's programme coverage (low, medium, high). We assessed differences in diagnosis of non-diabetic hyperglycaemia and type 2 diabetes and changes in cardiovascular risk (QRISK2 algorithm) using multilevel Cox and linear regression models. Propensity score, based on the probability of individuals being registered with a low, medium, or high coverage practice, was calculated. Analyses were by intention to screen. FindingsThere were 138 364, 131 679, and 100 411 individuals in the low, medium, and high coverage groups, respectively. The incidence rate of detected non-diabetic hyperglycaemia was 19% higher in the high coverage group than in the low coverage group (2781 vs 2479 cases; hazard ratio 1·19, 95% CI 1·01 to 1·41), and rates of type 2 diabetes diagnosis (4058, 4657, and 3827 cases in low, medium, and high coverage groups) were 10% higher in the medium coverage group (1·10, 1·03 to 1·18) and 11% higher in the high coverage group (1·11, 1·03 to 1·19). Individuals with detected non-diabetic hyperglycaemia in the high coverage group had a 1·1% larger reduction in cardiovascular risk than did those in the low coverage group (β=–1·12, 95% CI −1·61 to −0·63; mean follow-up 43·9 months), and those with detected type 2 diabetes a 0·4% larger reduction (−0·42, −0·78 to −0·06; 49·8 months). InterpretationAlthough only routinely collected information was used in this study, a robust methodology with a representative sample of the English population allows causal inference. General practices actively participating in a national diabetes screening programme had higher detection of non-diabetic hyperglycaemia and type 2 diabetes and, when newly detected, reduced cardiovascular risk. FundingPart funded by the National Institute for Health Research (NIHR) under the Collaboration for Leadership in Applied Health Research and Care programme Northwest London.

Contract and ownership type of general practices and patient experience in England: multilevel analysis of a national cross-sectional survey.

Objective To examine associations between the contract and ownership type of general practices and patient experience in England. Design Multilevel linear regression analysis of a national cross-sectional patient survey (General Practice Patient Survey). Setting All general practices in England in 2013-2014 ( n = 8017). Participants 903,357 survey respondents aged 18 years or over and registered with a general practice for six months or more (34.3% of 2,631,209 questionnaires sent). Main outcome measures Patient reports of experience across five measures: frequency of consulting a preferred doctor; ability to get a convenient appointment; rating of doctor communication skills; ease of contacting the practice by telephone; and overall experience (measured on four- or five-level interval scales from 0 to 100). Models adjusted for demographic and socioeconomic characteristics of respondents and general practice populations and a random intercept for each general practice. Results Most practices had a centrally negotiated contract with the UK government ('General Medical Services' 54.6%; 4337/7949). Few practices were limited companies with locally negotiated 'Alternative Provider Medical Services' contracts (1.2%; 98/7949); these practices provided worse overall experiences than General Medical Services practices (adjusted mean difference -3.04, 95% CI -4.15 to -1.94). Associations were consistent in direction across outcomes and largest in magnitude for frequency of consulting a preferred doctor (-12.78, 95% CI -15.17 to -10.39). Results were similar for practices owned by large organisations (defined as having ≥20 practices) which were uncommon (2.2%; 176/7949). Conclusions Patients registered to general practices owned by limited companies, including large organisations, reported worse experiences of their care than other patients in 2013-2014.

Implementing core NICE guidelines for osteoarthritis in primary care with a model consultation (MOSAICS): a cluster randomised controlled trial.

SummaryObjectiveTo determine the effectiveness of a model osteoarthritis consultation, compared with usual care, on physical function and uptake of National Institute for Health and Care Excellence (NICE) osteoarthritis recommendations, in adults ≥45 years consulting with peripheral joint pain in UK general practice.MethodTwo-arm cluster-randomised controlled trial with baseline health survey. Eight general practices in England. Participants: 525 adults ≥45 years consulting for peripheral joint pain, amongst 28,443 population survey recipients. Four intervention practices delivered the model osteoarthritis consultation to patients consulting with peripheral joint pain; four control practices continued usual care.The primary clinical outcome of the trial was the SF-12 physical component score (PCS) at 6 months; the main secondary outcome was uptake of NICE core recommendations by 6 months, measured by osteoarthritis quality indicators. A Linear Mixed Model was used to analyse clinical outcome data (SF-12 PCS). Differences in quality indicator outcomes were assessed using logistic regression.Results525 eligible participants were enrolled (mean age 67.3 years, SD 10.5; 59.6% female): 288 from intervention and 237 from control practices. There were no statistically significant differences in SF-12 PCS: mean difference at the 6-month primary endpoint was −0.37 (95% CI −2.32, 1.57). Uptake of core NICE recommendations by 6 months was statistically significantly higher in the intervention arm compared with control: e.g., increased written exercise information, 20.5% (7.9, 28.3).ConclusionWhilst uptake of core NICE recommendations was increased, there was no evidence of benefit of this intervention, as delivered in this pragmatic randomised trial, on the primary outcome of physical functioning at 6 months.Trial registrationISRCTN06984617.