Welcome back to the Hot Topics podcast from NB Medical with Dr Neal Tucker. In this episode, we think about the pay offer for practices in England, a new King’s Fund report on the under-funding of primary care for three decades, and the introduction of Pharmacy First.
In new research, we have two papers. First, in the BMJ, can an online combined exercise and psychological programme improve quality of life for patients struggling after hospitalisation with covid? Second, in JAMA, can serum urate levels help predict future flares of gout and guide us on who might benefit the most from urate-lowering therapy
References
Kings Fund Report on Primary Care
BMJ Post-covid-19 syndrome and online programme
JAMA Serum urate and recurrent gout
www.nbmedical.com/podcast
Welcome back to the Hot Topics podcast from NB Medical with Dr Neal Tucker. In this episode, we think about the pay offer for practices in England, a new King’s Fund report on the under-funding of primary care for three decades, and the introduction of Pharmacy First.
In new research, we have two papers. First, in the BMJ, can an online combined exercise and psychological programme improve quality of life for patients struggling after hospitalisation with covid? Second, in JAMA, can serum urate levels help predict future flares of gout and guide us on who might benefit the most from urate-lowering therapy
References
Kings Fund Report on Primary Care
BMJ Post-covid-19 syndrome and online programme
JAMA Serum urate and recurrent gout
www.nbmedical.com/podcast
I miss you. Come back to me. We were so good together. You'd come to me. I was there for you, helping you when you're under the weather. But there's someone else, there's someone new. You've gone away. What am I to do? You chose pharmacy first. Gp is second. I tell you it hurts, but here is still bad love. Is it taking a load off or does every cut hurt? You chose pharmacy first.
Speaker 2:You're GP's second To see a simple thing would mean so much to me. Something quick, please, something easy. Pharyngitis, sinusitis, empatigo, shingles, a herty ear, monsastitis, but now everything that comes to me. It feels so hard, it has such complexity. Cause you chose pharmacy first, gp's second. I tell you it hurts, but here is still bad love. Is it taking a load off, or does every cut hurt? You chose pharmacy first, you're GP's second. I tell you it hurts, but here is still bad love. One more cut Now. It barely registers. Cause you chose pharmacy first, gp's second, pharmacy first and I'm second.
Speaker 3:It's Friday, the 16th of February, and this is the Hot Topics podcast. Welcome back, everyone. Thanks for joining us once again on the Hot Topics podcast from NB Medical. I am Neil Tucker and in this episode we are going to be talking about two papers. Firstly, one on exercise to help with post-COVID syndrome. Secondly, one on urate levels as a predictor for future flares of gout.
Speaker 3:Now it's half term for me at the moment. I have limited time. I've managed to successfully palm the kids off into some kind of sporty clubs and then play dates. I've got a window of three hours which I've got to complete all this in. So, without your thinking, neil, the podcast is only 20 minutes. It surely doesn't take you that long to record it. I promise you it does. Oh, that my mind and my speech could be as fluid and as effective as my editing skills or, as I listen to myself even say this, that I could just be succinct for a while. It's no wonder I over run in my consultations, but succinct today I will try to be.
Speaker 3:So what have we got to tell you to start off with? Firstly, the office is petitioning me to tell you about our Valentine's NB Plus offer. You know what you're thinking you're thinking, neil, valentine's was two days ago or any length of time ago, depending on when you're listening to this. But don't worry, the offer continues until the 19th of February. Yes, I know what you're thinking. I'm thinking the same as well.
Speaker 3:Valentine's Day is just commercialization gone crazy, designed to sell pointless cards and an excessive amount of flowers. If you love someone, tell them. Tell them every day of the year, not just on the 14th of February, or, like we did at home, entirely ignore it. Until my wife came home from a day in the practice with a bunch of flowers. Were they for me? I thought no, she's not bought me flowers. I'd not bought her any either. There's no judgment here. This was from a patient, a bit of a wake-up call for me. Time for me to step up my game. I could buy her the best present of all, which would be a year subscription to MB+ With £25 off, making it just £295 for a year. Yes, it's the gift that keeps on giving. Do check that out if you haven't already signed up to MB+. What else is going on in the world of MB Medical Hot topics? We've got our new Hot Topics course coming out. I've been writing the slides for that over the last couple of weeks, along with my colleagues Simon Curtis, come and join me and some of my fantastic colleagues on Saturday, the 24th of February, when we'll be doing the first of our new season.
Speaker 3:And then let's think about the news. Well, what's been going on in the GP news over the last few weeks? Well, all hell has broken loose, but then I guess maybe it was already pretty much straining the leash. Anyway, if you're a GP partner in England, you will be very disappointed with the government's 1.9% pay increase offer, as disappointed as the BMA, which obviously said thanks but no thanks. It coincides with a new report from the Kings Fund. It's a very well-respected think tank which I'm sure has influence over policymakers, and in their latest report they just highlight for decades, successive governments have consistently failed to deliver on funding for primary and community care, and it says that it was one of the most significant and long-running policy failures for more than 30 years. Funding as a percentage of NHS spending has fallen in primary care over the last decade, whilst we're also doing a record number of appointments, with almost 32 million in November 2023. What's the solution? Well, they say, it's very simple we need a plan for more funding and staffing. Well, thank goodness for this new report, because none of us had ever thought of that one before.
Speaker 3:I actually haven't read the report in any detail, so I don't know if they go into more detail about Dot dot, dot. What did I say about being succinct? So just while I was in the middle of that sentence, I saw this butterfly has just landed on my bedroom window, which is where I record the podcast, and it's kind of like ready Brown with various dots around it. Very pretty. I had to look it up. It's called a peacock butterfly, oh, and it's just flown off, which reminds me really we should try and hurry up with this podcast and Get back to nature. In fact, I hope a few of you might be listening to this whilst you're out and about walking in the countryside Enjoying a bit of fresh air and some sunshine or some rain or whatever. Just get outside.
Speaker 3:Anyway, back to the Kings fund report, and I hope they thought a little bit about where they can put the money in Primary care. Where should it be going? Maybe we can direct a little bit more of it to general practice rather than just primary care, as the other big news from the last few weeks Is the start of pharmacy. First, patients can now go directly to their pharmacy. If they've got a cough or throat, ear infection, sinusitis, shingles, uti, have a consultation and maybe get some treatment. Patients may get better access and GP surgeries may get some of their workload shifted off of them. It sounds like a win-win.
Speaker 3:But there are a few issues here. Firstly, there may not be a pharmacist or enough pharmacist around to be able to deliver this service, because we've already Snaffled them all into general practice. Secondly, it's really only going to be the simplest of cases which can go and use this service. If people turn up with more complex issues, then they're inevitably Because the algorithm does this. It sends them back to us. So then pharmacies have done a consultation and will need to do a consultation, and patients will have done two consultations, which doesn't sound very efficient, speaking of efficiency. Thirdly, there's the cost. So pharmacies are paid 15 pounds per clinical pathways Consultation, which doesn't really sound very much to me. But pharmacies are also paid a 1000 pound fixed monthly payment if they meet their targets, and the minimum number of Consultations they need to do by October this year will be 30 per month. That's basically one a day.
Speaker 3:And if I was a smart pharmacy because I'm desperately trying to run a business that has had its Funding repeatedly reduced over the last few years by the government what I would do is Absolutely stick to the minimum so that it maximizes the amount I earn per consultation. By doing that, you would earn 48 pounds per consultation. Now, of course, those of you in general practice might start thinking well, hang on a second. What if I could see loads of easy stuff and someone paid me 48 pounds per Consultation? Wouldn't that be great? Well, wouldn't it be even more great if some of that funding was actually to make its way back to practices, as Copperfield in his column in pulse points out? Actually, wouldn't it be great if GPS saw more of this, because we are brilliant at what we do and indeed we might think this is simple, but it's only simple because we're really good at it. And if patients came to us, then they wouldn't need to refer themselves back to their GP because we are their GPS and we Could sort out all the other problems they come with at the same time. Which seems to bring us back full circle to the idea about bringing more funding into general practice. I know, I know I'm preaching to the converted right soon, as we're not going to fix this anytime soon. Let's move on to the research and see if that can maybe help fix some other things.
Speaker 3:So first you can have a look at a BMJ paper that published this week on Long, covid and exercise. In fact, the specific title was clinical effectiveness of an online supervised group physical and mental health Rehabilitation program for adults with post COVID-19 condition. This is called the regain study. I'm not quite sure how they derived that acronym from the title, but maybe you don't need to actually have all the letters. I don't know. I get a bit confused with this sometimes. I thought this was a really interesting paper and a really interesting idea and one that's really useful to explore.
Speaker 3:There's obviously been a swing in the past few years. Covid, of course, has not been around that long, but before long Covid came along, people were getting chronic fatigue. We didn't really understand why. There's always a suspicion that there was going to be some kind of underlying infective driver, at least for some of these individuals. But given the absence of an obvious treatable cause, often people were recommended to do graded exercise. Clearly this was a very contentious issue. Lots of people with chronic fatigue say that this actually makes them worse, and we saw this swing towards a different approach, and one of the central themes around this more holistic approach is about pacing, planning and prioritising activity. I have a friend who has really bad long Covid and this is absolutely what she needs to do. She's tried graded exercise, she is very motivated, but it just doesn't seem to work for her and she absolutely needs to be very mindful about the level of activity that she can introduce on any day Because of the effects it will have over the coming days and weeks. Anecdotes can be a very powerful learning tool, but they can also bias us quite substantially at times, and just because it doesn't work for her and she needs a different approach doesn't mean that it couldn't work for others. So I'm really glad that the authors of this paper have taken this on.
Speaker 3:So this was a pragmatic multi-center superiority randomised control trials set in England and Wales comparing best practice, usual care, which they class as a single online session of advice and support with a trained practitioner, against the Regain programme, which was an online programme delivered over eight weeks consisting of weekly home-based live supervised group exercise and psychological support sessions. Sounds a bit like they've kind of squashed Peloton and Mind together. They specifically recruited adults who had been admitted to hospital with COVID-19 and then had ongoing physical and or mental health sequelae for at least three months. They then checked what their quality of life was, both at the start and at three months. That was their primary outcome, with secondary outcomes being measured at three, six and 12 months, including a wide range of features like depression, fatigue, pain, physical function, general health and adverse events as well. So out of almost 40,000 people who were invited, they ended up with just about 600 people enrolled in the study. Mean age was 56, 52 per cent were female and on average, they'd been discharged from hospital almost 11 months before recruitment.
Speaker 3:It's worth just chatting a little bit more about the intervention that they had. So patients had initially a one hour online one to one consultation with a regain practitioner, where they had time to talk about their illness and the enduring effects that it's had the practical effects that it's had on their life as well. Then they were enrolled in a weekly live online exercise group which they could also, and were encouraged to, access on demand at other points. In addition, they had six live online group psychological support sessions. These were semi-structured and gave people the opportunity to talk about a variety of different topics, including things like motivation, fear, avoidance, activity, pacing, managing setbacks, sleep, fatigue, stress, anxiety as well All in all, pretty intense.
Speaker 3:Did it work then? Well, there were statistically significant improvements in quality of life, largely driven by reductions in depression, fatigue and pain scores, but, interestingly, the effects size overall was low. The authors acknowledged that, despite there being a demonstrable difference between what could be attributed to natural recovery and best practice, usual care, when taking the intervention group as a whole, it suggests that it may not meet the minimally important clinical difference. Part of the problem here was adherence, so 47% of participants adhered fully to the intervention, 39% partially and 13% didn't even turn up. If you just focus on that fully adherence group, things look a bit rosier and their results did come out much better and they did show more clinically meaningful improvement. The authors conclude that in adults with post COVID-19 condition, an online home based supervised group physical and mental health rehabilitation program was clinically effective at improving health related quality of life at three and 12 months, compared with usual care.
Speaker 3:Now, off the basis of the results they've published, you and I might think that that sounds a little bit generous and I think that's fair, but I think if we apply some of the principles to managing long COVID and chronic fatigue conditions, then this research still provides useful information for us and our patients. I think the key message is that you have to adopt a holistic approach here, because one size doesn't fit all. It's not going to work for everyone. If you have a person who feels like they're motivated enough and well enough to be able to engage with these programs, then fantastic, they should take part. There's a good chance that they're going to improve as a result of that. If people feel like they won't be able to do this or it's just not for them, then let's not try and push them into it. It's just not going to work. They need a different approach.
Speaker 3:The authors felt that this was an intervention that could be scaled up while keeping it cost effective. And you will need to scale these things up because there's a lot of long COVID and a lot of people struggling out there. Online exercise groups is a great way to go. That's easy to scale up. I'm not so sure about the initial one hour consultation with a dedicated regain practitioner. That sounds much harder to me. And also there comes a point when you're doing group based psychological therapy, that a group might get too big and overwhelming and then people start getting less out of it, and that's going to need some consideration. One thing that we don't have a lot of at the moment is spare mental health stuff. Nevertheless, I don't want to be too negative about this, because this is a positive study and it does go to show that there is a way to help people with enduring symptoms after COVID.
Speaker 3:Okay, and now for something completely different. We're going to be thinking about gout, a problem as old as the human race, in a true general practice classic. It's a funny old business, though, because all of us, I'm sure, when we've got someone who has their first episode of suspected gout, we'll check a urate level. Right Guidelines, indeed, say check a urate level, but NICE also says there is no clinical evidence on diagnosing gout through history examination or serum urate levels. Regardless, it still suggests that you should check it and if there's a level of greater than 360, that supports the diagnosis. But it also suggests that the urate levels can go down during acute flares, which is when most of us would actually check the bloods to help make the diagnosis. So perhaps things aren't as straightforward as they seem. Nevertheless, I think most of us still buy into the idea that urate levels can guide on diagnosis. I don't think most of us would use them, though, to make decisions on long term therapy that's more guided by the presence of flares.
Speaker 3:A few years ago, on the Hot Topics course, we presented new recommendations in international guidelines that suggested, if you'd even had one episode of gout, that you should be on urate lowering therapy. And that was because specialists thought you would still get potentially subclinical effects from gout, eventually increasing your chance of joint destruction and arthritis. Primary care clinicians went oh, that feels like a lot of medication. And patients went well, I've got to take this lifelong medication because I've just had one episode of gout. Can't I just give up the port and pheasant? And then the specialists and guidelines backtracked a bit on all of this and they said well, okay, maybe you should have urate lowering therapy if you get recurrent or troublesome flares. What does all this flip-flopping tell us? Well, basically, we don't really know what's best for people, but, just like essentially any other disease that has flares in severity, flares of gout are generally considered bad news that they may lead to some irreversible joint damage, and it's not just simply being acutely inconvenient. So wouldn't it be great if we had a way of predicting your chance of having future flares if you've had gout? Well, hang on a second, I hear you cry.
Speaker 3:What about checking urate levels? Now it sounds like a really obvious thing to do, but this has not been researched before. So this was a paper published in JAMA last week. This was examining whether higher serum urate levels are associated with higher incidents of gout flares. So this was a retrospective study using UK data pulled from the UK Biobank. They examined 3,600 patients' records who had a diagnosis of gout, followed up on average for eight years, and the main outcome measure was the rate of recurrent acute gout in relation to a single urate level which had been checked at their point of enrollment into the study. This is another great example of the benefits of this UK Biobank study. Being very systematic about how you collect data and how you follow these patients up over time helps generate a wealth of insights into long-term health.
Speaker 3:Anyway, to cut a long story short, were urate levels and flares associated? Yes, they were absolutely so. If your initial urate levels were 360 or less, then there was a rate of 10 flares per thousand person. Years Go up to 360 to 420. That's when we're starting to get more interested and think, oh OK, this person, maybe they have gout. Then that rate quadrupled to 40. From 420 to 480, it doubled again to 82. If your urate level was even higher than that, then your risk of having an acute flare went up even further, but it did start to plateau a little bit by the time you got to the 600 mark.
Speaker 3:The authors noted that 95% of acute flares occurred in people with a urate level of greater than 360, which is perhaps not a surprise to most of us, because that's what we're trying to get people's urate levels down below if we want to prevent them having flares. They looked at other factors as well, such as BMI, smoking, alcohol intake, coffee use, red meat and all of those kind of things. Interestingly, none of those factors seem to influence the chance of you developing acute flares. In conclusion, higher urate levels is linked to higher rates of flares. The higher you go, the more likely you are to have one. The authors felt that this supported a baseline serum urate level to help assess the risk of recurring gout in the future.
Speaker 3:What does this mean for us in general practice? Should we be changing what we do based on this data. I mean it's quite compelling, but we need to keep in mind that it is observational. There are other issues as well, so there are lots of people out there who have high urates levels but have never had an episode of gout. Urate levels themselves can fluctuate, so a one-off marker may not be as useful at all as perhaps a number of markers over time. The linked editorial suggests that more work needs to be done in this area, ideally through prospective studies, particularly examining if there are specific levels that would merit secondary prevention.
Speaker 3:What am I going to take away from this? I think if you've got a patient who's had a couple of episodes of gout and they're on the fence about whether to have allopurinol or not, I think it's worth us just taking a quick peek at the serum urate levels, and if it is staggeringly high, there's a good chance they're going to have another episode again and that might just help make that decision a little bit easier. Goodness knows, it's nice to have something that makes decision making easier. Okay, that's it for today. Thanks for joining us on the podcast once again. Don't forget to check out the website mbmedicalcom for that Valentine's Day MB Plus offer and all the courses that are coming up. Hopefully I'll see you on that Hot Topics course on Saturday, the 24th, and if not, I'll see you on the podcast in three weeks time. Take care, we'll be back.