S5 E10: Doctors Are Cheaper than Nondoctors; Familial Hypercholesterolaemia Under-Recognised; Helping Older People Stay at Home

Welcome back to the Hot Topics podcast from NB Medical with host Dr Neal Tucker. In this episode, we start by thinking about the news. Firstly, the overwhelming consensus from GPs in England to not support the imposed contract.

Secondly, the ongoing discussion around physician associates in general practice, where we touch on an interesting report from South Mississippi around the costs and other outcomes of non-doctor-led primary care. Thirdly, NHS patient satisfaction - is important to take note but why does staff satisfaction never hit the headlines?

In research, we look at two papers. First, the rate of familial hypercholesterolaemia coded in practices - how far are we away from what we should expect? And in those with a diagnosis, how good are we at optimally treating them? Second, a paper on which interventions might help people maintain their independence. After an estimated £1.15 billion pounds of research in this area, what does this new systematic review and network meta-analysis tell us?

References

AMA Report on PA/NA from South Mississippi
NHS Staff Survery Results
BJGP Familial Hypercholesterolaemia rates in GP
NICE Guideline FH
Simon Broome Diagnostic Criteria for FH
BMJ Community Interventions to Maintain Independence

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Transcript

Speaker 1: 0:00

It's Thursday, the 28th of March, and this is the Hot Topics Podcast. Welcome to the Hot Topics Podcast from MB Medical, neil Tucker, here. Once again, it's the Thursday before Easter. I hope that some of you are going to have a lovely four day break before the obvious, inevitable carnage on the Tuesday in GP practices after Easter. We were chatting about this at work the other day and in the end we decided that, whilst it's pretty close, on balance, it does come out still as a good thing. Shame about the weather, which is currently gross.

Speaker 1: 0:42

This is not unexpected, I guess, and I have to be really succinct today because, as those of you who have children will have experienced in the past, as it's the last day before one of the big holidays, the schools close early, so I've got to pick my kids up at two o'clock, which doesn't leave me a lot of time to do the podcast today. It's a curious phenomenon. I have teacher friends. I've never actually asked them why they do this. I've always presumed it's because they need a bit of time to tidy things up and get things sorted before they literally close the shop up for the holidays, and I just wonder if we could extend this concept into general practice just close up a couple of hours early on the Thursday before Easter or on Christmas Eve so that we can get everything tidied up nicely and get home on time, although I now see it as I'm talking that the logical extension here is to do that before every weekend or indeed perhaps at the end of every day. And clearly here only lies madness. Let's move on, and in the podcast today we're going to be talking about two pieces of research one in the BJGP on the amount of people with familial hypercholesterolemia that we identify in general practice, and then an interesting network meta-analysis and systematic review in the bmj on community-based complex interventions to sustain independence in older people.

Speaker 1: 1:59

First nb news, so nb medical. We get a little bit quiet over the holidays, but just after the Easter holidays we'll be back. We'll be doing a live webinar of the latest Hot Topics course also coming up in May we've got our brand new course, which is Hot Topics in Primary Care, cardiology and ECG. So if you want a bit of a refresher on ECG interpretation and a range of important cardiology topics that we never have time to do on the main Hot Topics course, then this is the course for you. So that's on the 27th of April, that's a Saturday. It's a half-day morning live webinar as well, run by the fantastic Dr Nick Jones, who's a GP and gypsy in cardiology and researcher in cardiology as well. He knows a lot about cardiology. If you're thinking of signing up for one of those, then think about signing up for NB Plus, our subscription service. We have an Easter deal running at the moment until the 31st of March, where you get £25 off, making it even more of a bargain. I think that makes it just under £300 for a whole year and you can come on all of our live webinars, watch them all on demand. You can have access to all of the online booklets that we do, all the fantastic online educational modules, safeguarding resources and lots more besides.

Speaker 1: 3:24

What else has been going on in the wider news? Well, the BMA have been polling GP members about whether they accept the imposed contract from NHS England. Of course, if you're an English GP, and apparently on breaking news on Pulse literally just now, they've said 99% of GPs vote no for accepting the imposed contract. The other 1%, presumably, are either complete masochists or pressed the wrong button. This is not the same as voting for industrial action. That's a different question that needs to be posed by the BMA, and they've already set out a timeline for this. So we can expect balloting on this in September for this, so we can expect balloting on this in September. Meanwhile, the BMA is being very successful in keeping its profile high and keeping them in the news.

Speaker 1: 4:10

With this discussion around physician associates at the moment, what's really fascinating to me is the lack of insight or foresight that authorities seem to have around the introduction of an entirely new group of clinicians into the health service. The GMC is now currently consulting on the possible rules and standards that PAs will have to adhere to. You would have thought and this is not the GMC's fault, because of course they've only just taken on this role, but you would have thought that may have been something to consider in advance. Of course, it's also not the fault of the PAs themselves, who have just been dumped in this situation. These people let's not forget that they're people, and people that we work with, many of us will work with on a day-to-day basis saw the opportunity for an interesting piece of career development or a changing career. They've gone through a training program and then dumped in a system that's been slowly dismembered over the course of the last year. It's like taking someone else's hand and sticking it back on the stump of where that dismembered arm used to be. The hand is clearly different. That's not necessarily a bad thing. It can still perform a whole range of useful functions. Just don't expect it to wipe its own arse.

Speaker 1: 5:25

Nhs England, which is obviously part culpable in driving this whole process, has released new guidance saying that all practices who employ physician associates must have a policy to restrict access to prescribing. It also highlights that they are not meant to be substitute for GPs and they must be supervised and debriefed by a GP. So perhaps this is actually taking shot at, I think, maybe those larger companies, some of those big corporations that have been buying up general practice and trying to look at ways to cut costs and start wholesale replacing GPs with less experienced and less qualified staff. This, of course, is on the premise that it's cheaper to do that. You can save the nhs money. But this was really fascinating.

Speaker 1: 6:13

So I was reading an, a blog from helen salisbury. So she's a gp in oxford who writes this uh weekly blog has done for years and years in the bmj, and in it she highlights a report from the american medical association. The report highlights real-world data from South Mississippi and a large medical organisation there with a big primary care department where the entirety of patients' care may be undertaken by physician assistants, as they're known there, or by nurse practitioners instead of GPs. They examined the costs and they found that, after they risk adjusted for patient complexity, if your primary care provider was a non-doctor, then the average cost of your medical care was $119 per member per month higher than if you were looked after principally by a doctor. To put that in an overall system cost that came out at $28.5 million more expensive per year. This was based on data from a medical centre looking after 33,000 patients, so that sounds pretty much like a PCN-sized group to me. So if I was a policymaker in government or I was running an ICB, to me this would sound like very, very important information. Of course, it's not all about money. They also looked at clinical processes so important clinical outcomes and patient satisfaction too, and the vast majority were better with doctor versus non-doctor care.

Speaker 1: 7:48

The BMA feels that GPs face an existential threat from additional role, staff replacing what we do and gradual mission creep, as this report shows. That would be very costly if that were true. Personally, I don't think that's what the government is actually up to. I think they're just plastering over the gaps that have appeared over the years because they've stuffed up recruitment and training. Unfortunately, this report probably comes too late to be a prescient warning to the UK, because you may think that, this being an American system, the reason they tried to introduce physician assistants and nurse practitioners was from a money perspective. But it wasn't. It was because, they said in the report, over the past 15 years, in the face of physician shortages, especially in primary care, they had to make decisions to expand our care teams with the use of advanced practice providers. This wasn't driven by money. This was driven by staffing issues. This, incidentally, had been one of the key issues raised by patients in the latest NHS patient satisfaction survey. So this hit the news yesterday with the headlines patient satisfaction at an all time low in the NHS.

Speaker 1: 9:02

As people working in the NHS, I find it a little bit hard not to take these things a bit personally. The thing I find particularly irritating is you always get the news reports of how badly people feel the NHS is doing. You never see any news reports about staff satisfaction. So I thought I'd google it and lo and behold. In fact, in the last few weeks, the NHS has published its latest staff satisfaction survey as well. Now I should highlight that I don't think this actually incorporated staff from general practice, but I'm sure we can draw lots of parallels.

Speaker 1: 9:38

Now, once you get over the vomit inducing soundbite titles for each of the areas that they asked about, I'll give you a couple of examples. So the first one was we are passionate and inclusive, and the second is we are recognised and rewarded. Honestly, I have absolutely no idea who comes up with this stuff, but some of the key things to come out of it. Less than half of workers are satisfied with their organisation values its work. Less than a third are satisfied with pay. Less than a third report there's enough staff. 55% have gone to work despite not being well enough to work. 24% are thinking of leaving in the next year. 21% want a new job outside of the organization.

Speaker 1: 10:23

This is pretty dismal too. None of this is getting the front page of the daily mail. Oh, it's getting a bit heavy now, isn't it? So I feel like we need to. I need to change this and be a bit more upbeat. I think the positive thing that we can take out from this is despite what we hear in the surveys, when you're working in the practice and you're actually seeing the patient, they're very happy with the care that they get. The main bugbear is access to a GP. I've suggested solutions to this before. It's going to cost more money. Thankfully, in the survey people actually say they might be prepared to pay a little bit more through taxation to fund the health service better. I think we'll all believe it when we see it.

Speaker 1: 11:00

Okay, let's get on with the research. So the first of our papers. It was in the BJGP this month with the title familial hypercholesterolemia in uk primary care a clinical practice research data link study of an under-recognized condition. This is another great example of the power and utility of the information that we're recording day-to-day in general practice. Familial hypercholesterolemia, then it's a genetic condition which causes high cholesterol in individuals and then you have a very high chance of having a cardiac event at younger age. The good news is, if we can identify it early, we can get people on lipid lowering therapy, which will hopefully improve their outcomes in the long, long term.

Speaker 1: 11:42

Now the authors report that recent advances in genotyping methods now suggest the prevalence of familial hypercholesterolemia could be as high as 1 in 137 of the adult population. The aim of this study, then, was to estimate the prevalence of familial hypercholesterolemia by the age of 18. Based on what we've coded in our patients in general practice. So this was a retrospective analysis looking at the study cohort so our primary care databases on the 30th of June 2018. This gave them a point prevalence of familial hypercholesterolemia, and then they also collected information about their lipid levels and their lipid treatments. 2.77 million patients met their inclusion and exclusion criteria, of which 4,408 were recorded with a diagnosis of familial hypercholesterolemia. That works out as about 1 in 600, which is much lower than we might anticipate based on that latest genetic data.

Speaker 1: 12:46

The authors suggest that, then, somewhere between 50 and 75% of patients with this condition are undiagnosed and therefore, of course, are not getting the treatment that could be potentially life-saving for them. What can we do about this in general practice? Well, of course, there's no screening program for this and there's no incentivization schemes to look for these patients currently, but I think if you wanted to do a bit of simple quality improvement, you could just search your practice population for those with raised cholesterol levels and consider doing a bit of a case review of individuals that have had a cardiovascular event at a young age? Have we checked their cholesterol? Are they on appropriate treatment? And, really importantly, have we thought about their family as well? And if they have their cholesterol levels checked? I think it would be a relatively quick thing to do to identify this group and it could, of course, potentially be life-saving.

Speaker 1: 13:36

The other issue they highlighted in the paper was that one in three people who already have a diagnosis of familial hyper cholesterolemia are undertreated, and what they actually mean by that is a third of patients haven't had a recent prescription for any lipid lowering therapy. The actual number who are undertreated, I think, must be much, much higher, because they report about mean lipid levels in the treated versus untreated population who do have a diagnosis, and the LDL in those on treatment is 3.15 millimoles per litre on average, compared with 3.96 millimoles per litre in those who are not receiving treatment. But what I take from that is that most of these patients don't sound like they're doing great. The NICE guidance on familial hypercholesterolemia recommends that we should be aiming for a 50% or greater reduction in LDL levels from baseline in this group, given the fact that on the Hot Topics course at the moment we're talking about recommendations for, albeit secondary prevention of cardiovascular disease through lipid lowering therapy, looking for a target LDL of less than two. It feels like in this very high risk population, that the targets are a bit weak. We're aiming low, or rather we're not aiming low enough. If I was one of this group, I would want all the meds and for my LDL to be super low. Fancy a dash of a zetam with that, sir, don't mind if I do.

Speaker 1: 15:06

Our second piece of research was published in the BMJ last week with the title Community-Based Complex Interventions to Sustain Independence in Older People Systematic Review and Network Meta-Analysis. Now I know what you're thinking. It doesn't sound hugely interesting, right? But I think this is a really important area. Good news on average, we're all going to live to an older age. One of the key priorities that older people report is maintaining their independence and staying in their own homes. Given the fact that if you end up in care or in a hospital, then that's really expensive compared with staying in your own home and of course, it's worse for the patient, it's not what they want to do then actually finding an intervention or the best way to keep people in their own homes is really, really important, in fact so important that last the chief medical officer made it a policy priority for England.

Speaker 1: 16:08

Now there have been many pieces of research on this over the years, often with conflicting results. This partly explains why for years we had this community matron program and we used to have a fantastic nurse at my old practice called Lucy. We had lots of great nurses at the practice, but Lucy took on the community matron role and would go and assess patients. She'd go to their homes, she would do care planning, she would assess their general health. If there were any specific concerns she would flag them up. It felt like a great idea. Patients really liked it and then we had some research that shows that it didn't make any cost difference overall. Shortly after the research that shows that it didn't make any cost difference overall, shortly after the whole scheme was scrapped.

Speaker 1: 16:49

When there's lots of different research, of course you can undertake a systematic review. That's been done before and suggested that there are interventions that may have a small but positive effect. It's tricky to quantify this and also compare against different interventions. But, as the authors state, this field has developed strongly and what this new paper adds is this network meta-analysis, which means you don't just have to compare two types of interventions. In a meta-analysis you can compare multiple ones simultaneously. I will admit this does make it quite challenging to share some of the detail with you on a podcast, but I think we can keep things fairly straightforward.

Speaker 1: 17:30

So they included 129 studies that included 75,000 participants, so 61% of those were women, 39% men. The studies had to be randomized controlled trials or cluster randomized controlled trials with at least 24 weeks follow-up in older people, so at least age 65 plus. Given their randomized controlled trials, they would have the intervention group and then they had to have either usual care, placebo or another complex intervention. As a comparator, they identified 19 different components to community-based complex interventions, so they could be action components such as activities of daily living, training, providing aids and adaptation, cognitive training, health education, physical exercise, formal home care, nutrition support and more. Also tailoring components such as medication review, monitoring, routine reviews or multifactorial action from individualized care planning and more again. From this alone it's easy to see why it's so hard to work out which individual components of any type of intervention given the fact that probably most people are having multiple things done simultaneously by us which ones actually lead to any benefit, if there's any benefit at all, or indeed, which ones might make people worse? To cut a very long story short, they concluded that the intervention most likely to sustain independence is individualized care planning, including medicines, optimization and regular follow-up reviews.

Speaker 1: 19:15

The authors suggest that, given the overall evidence for their benefits, we recommend access to these interventions and services for older people. I think the positives that we can take away from this in general practice is that we have systems in place which mean that we do do medication reviews on a regular basis, at least annually, for all of our patients. We also still do care planning. I feel like it's not quite as high on the agenda as it was a decade ago and I highly suspect that if we had a practice nurse to be community matron who could coordinate our high-risk patients and go out and see them on a not infrequent basis, that that would lead to better outcomes. But at least most practices will have systems in place to help make sure that care planning happens.

Speaker 1: 20:01

The idea about regular follow-ups is something which I think perhaps we may need to think about as practices. Again, it may be that many of you will have good systems in place for this. Many of you will have your own patients that you will make sure you follow up in a timely fashion as their illnesses dictate. But I also suspect for many of us, as our patients become more unwell and more housebound as our patients become more unwell and more housebound, where there's greater reliance on using other services, such as paramedic teams to go out and do home visits for practices, it's quite easy for this group to get a little bit left behind.

Speaker 1: 20:36

The paper also highlights that a combination of exercise and nutritional support was favourable. This perhaps is no surprise to me. It just highlights that there's limitations to what we can do in general practice. Yet we can help out, but patients also need to take some ownership of these issues themselves.

Speaker 1: 20:54

Staying active, keeping on moving, is one of the most important things you can do as you get older. I went to a talk recently from a chap called Sir Muir Gray. He is a physician who's had really important roles in public health and the health service over many, many decades, and he's written a number of books for the public on the importance of staying active as we get older. The idea of keeping moving is a very simple message. Perhaps it's one that we should be, and could be, pushing a little bit more. Okay, that's enough for today. Thank you for listening once again. As ever, remember, you can get in touch so hottopics at nbmedicalcom if you want to email or find us on Twitter and Facebook. Don't forget that current Easter NB Plus offer and all the courses we've got coming up once the Easter holidays are done and I'll be back in three weeks. See you then, bye-bye.