Tuesday, 26 April 2016

The resources debacle

Lancet. 2016 Apr 5. pii: S0140-6736(16)00620-6. doi: 10.1016/S0140-6736(16)00620-6. [Epub ahead of print]

Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007-14.

Hobbs FD, Bankhead C, Mukhtar T, Stevens S, Perera-Salazar R, Holt T, Salisbury C; National Institute for Health Research School for Primary CareResearch.

Abstract

BACKGROUND:

Primary care is the main source of health care in many health systems, including the UK National Health Service (NHS), but few objective data exist for the volume and nature of primary care activity. With rising concerns that NHS primary care workload has increased substantially, we aimed to assess the direct clinical workload of general practitioners (GPs) and practice nurses in primary care in the UK.

METHODS:

We did a retrospective analysis of GP and nurse consultations of non-temporary patients registered at 398 English general practices between April, 2007, and March, 2014. We used data from electronic health records routinely entered in the Clinical Practice Research Datalink, and linked CPRD data to national datasets. Trends in age-standardised and sex-standardised consultation rates were modelled with joinpoint regression analysis.

FINDINGS:

The dataset comprised 101 818 352 consultations and 20 626 297 person-years of observation. The crude annual consultation rate per person increased by 10·51%, from 4·67 in 2007-08, to 5·16 in 2013-14. Consultation rates were highest in infants (age 0-4 years) and elderly people (≥85 years), and were higher for female patients than for male patients of all ages. The greatest increases in age-standardised and sex-standardised rates were in GPs, with a rise of 12·36% per 10 000 person-years, compared with 0·9% for practice nurses. GP telephone consultation rates doubled, compared with a 5·20% rise in surgery consultations, which accounted for 90% of all consultations. The mean duration of GP surgery consultations increased by 6·7%, from 8·65 min (95% CI 8·64-8·65) to 9·22 min (9·22-9·23), and overall workload increased by 16%.

INTERPRETATION:

Our findings show a substantial increase in practice consultation rates, average consultation duration, and total patient-facing clinical workload in English general practice. These results suggest that English primary care as currently delivered could be reaching saturation point. Notably, our data only explore direct clinical workload and not indirect activities and professional duties, which have probably also increased. This and additional research questions, including the outcomes of workload changes on other sectors of health care, need urgent answers for primary care provision internationally.

Image: Overcrowded train in Bangladesh of devotees returning from the World Moslem Congregation.

Figure: Population of the UK 64.1 million (2013), life expectancy 81.5 years.

The debate on population dynamics is not mere verbal wrangling, or 'the second coming' caused by migration as the politicians would have you believe, but a realistic and tangible threat for every nation over the next +10 years. We are fast approaching a point where the amount of resources needed to sustain the worlds population exceeds the available resources, and healthcare availability plays a major role in this (have you wondered why in the US with a population size of 318.9 million the Obama healthcare reform is being strongly opposed?). I'm not sure containment is the answer here, or better still waiting for the zombie apocalypse.

In the UK the primary care is central to the provision of Healthcare, a model followed by many countries, and is likely to demonstrate the first signs of weakening as it is overwhelmed by unsustainable increases in workload. It is also the gatekeeper for secondary healthcare and failings here lead to deficits in the latter. Based on the findings from this study, the number of consultations per patient per year in UK rose by roughly 10% between 2007/8 and 2013/4. Most were face-to-face contacts with GPs (rather than the practice nurse). The rate of rise in consultations were linked to demand from extremes of the age spectrum - infants (the birth rate debacle) and the elderly (the Damocles of successful advancements in the field medicine debacle). And to consultation duration (12.4% increase in GP consultation rates linked to 4% rise in mean consultation duration). A common strategy advocated to cope with the rising workload has been to utilise the telephone triaging, but with a doubling in the telephone consulting rates over time and in about a third also resulting in a subsequent surgery consultation, has meant that it does not reduce workload in the long run.

So the pressure felt by many practices is well founded, and the whole system is fast approaching saturation point. It's probably not the time for austerity/efficiency savings, but the exact opposite. Now where did I put my piggy bank?

18 comments:

  1. You are wrong, Gnanapavan. Read George Friedman's book 'The Next 100 Years' and you'll find that the world population will in fact decrease. America and Europe will be begging for immigrants to move here to work and stuff. We're not having enough babies ourselves.

    The world population is about to reverse.

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    1. We can pick up this discussion in another 100y - I'll put it in a time capsule just to be safe.

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  2. Resistance to Obamacare has little to do with limited resources. Which is not to say we wouldn't do well to train more medical professionals, incorporate telemedicine, use more robots, etc. But to fully understand the Obamacare backlash, you have to look more closely at who profited from our awful old system, political divides, and, yes, race issues in the US.

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    1. Admittedly not the only cause, but can't be discounted. Having tried my hand at these various methods of reviewing patients, I've come to the conclusion that only healthy people don't make a repeat appointment. Instead they generate extra paper work, you can't examine patients - very important in neurology, and people forget what was discussed.

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  3. The populations of Europe, North America and Japan are aging rapidly in return for very low birth rate. By contrast in Asia, in South and Central America and Africa the high birth rate without the accompanying technological development (scientific and educational), sanitation / health and economic these regions and cover much of the population, then the what you see are "pockets": a tip occur many births (among the lower classes of society), at the other end to population aging (especially those that make up the middle class in these countries) and in the middle of a huge mass of young people without qualifications and outlook on life, generating all this situation of unbridled immigration and chaos ...

    I'm not talking about birth control or anything like that, just reflect about the lack of perspective in certain regions of the world, and that the solution to this problem is much deeper, time consuming, and suffer part by resistance from those who do not want this to happen...

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    1. Yes, we do skirt around the issue a lot. I think burying our heads is much easier to do. On the one hand we have made people survive longer, but mostly we take care of what is already there less. The only way to continue going as we are is to invest time and money into solutions.

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    2. Women in Britain are giving birth at an average rate of 1.9 children each, higher than other major European nations like Germany. Germany is 1.4. Figures from Dec 2015. UK born women are not having many babies due to choice, medical reasons, financial reasons etc. Immigrants are keeping the rate up apparently.

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  4. I think that the role of the primary care doctor will change radically in the next few years. I see the primary care doctor as a diagnosition and case manager. We're not far away from a wearable that will monitor us in realtime.

    Why wouldn't my watch monitor me and then my printer would 'Walter White' the medication?

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    1. If you looked back to the old days, the GP's role was as a diagnostician and case manager - hence the term family practitioner, but medicine has moved on, and villages are now towns and it becomes harder to deliver the same level of care/service.
      I'm all for wearable devices, in the case of MS something that accurately tracks motor relapses to allow earlier treatment. Sensory relapses although important would be difficult to capture on these devices and rely on self reporting. These devices also need to fit in seamlessly into your lifestyle, there is also the issue of 'big brother' is watching you type of feeling which the older generation do not like the idea of!

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    2. Re: in the case of MS something that accurately tracks motor relapses to allow earlier treatment.
      What about relapses from brain stem lesions such as double vision? Medulla lesions? That wouldn't be classed as sensory would it?

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    3. Brain stem relapses are indirectly captured by activity monitors, perceptive problems unless severe want be.

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  5. Aidan, I think we're probably farther away from wearables than you think - we need a breakthrough in blood analysis and monitoring. We currently can't do that without a poke, and a sample. Having a wearable that did this could be tricky, due to the risk of infection, and getting people to wear something that's going to stick them X times per day. :|

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  6. Fair point that a wearable might be further away than I think. But what could we do today to help get there? Would there be any point in having a number of MSer getting regular (3 times a week) blood draws and mapping out the WBC population? If we had that data might we find something?

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    1. Ifs, ifs...I spend most of my work day contemplating this question. Working in the biomarker field, a good sample set, collected appropriately and longitudinally is invaluable. This costs time - peoples who volunteer for these, and money - research bodies funding these. So one way to get around this is to piggy back these onto clinical trials, which is what we do.

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    2. Are there many diabetics with MS? They collect blood samples daily - small amounts, but it's enough for glucose testing. With modern technology, one can run multiple analytes in a drop of blood. The lack of indicator strips may be limiting today - but paper diagnostics is burgeoning, so tomorrow, one may be able to have a good set of data on multiple biomarkers daily. And piggy backing on diabetics running daily glucose tests may be rather easy logistically.

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    3. Strip analysers are a good idea, the Guthrie card for testing metabolic disorders in the new born is an example. This blood can be fed into a tandem mass spectrometer which will allow you to look at a lot of proteins with only a small quantity of sample. At the moment everyone is trying to maximise the number proteins which can be measured in a small volume of sample - Affymetrix, Simova, Cytomix; but they remain in research and not in direct clinical practice as reducing the volume for measurement also reduces accuracy. But watch this space, more papers are expected to be published in this area in MS.

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