Mainstreaming adult ADHD into primary care in the UK: guidance, practice, and best practice recommendations

BACKGROUND

ADHD in adults is a common and debilitating neurodevelopmental mental health condition. Yet, diagnosis, clinical management and monitoring are frequently constrained by scarce resources, low capacity in specialist services and limited awareness or training in both primary and secondary care. As a result, many people with ADHD experience serious barriers in accessing the care they need.

METHODS

Professionals across primary, secondary, and tertiary care met to discuss adult ADHD clinical care in the United Kingdom. Discussions identified constraints in service provision, and service delivery models with potential to improve healthcare access and delivery. The group aimed to provide a roadmap for improving access to ADHD treatment, identifying avenues for improving provision under current constraints, and innovating provision in the longer-term. National Institute for Health and Care Excellence (NICE) guidelines were used as a benchmark in discussions.

RESULTS

The group identified three interrelated constraints. First, inconsistent interpretation of what constitutes a 'specialist' in the context of delivering ADHD care. Second, restriction of service delivery to limited capacity secondary or tertiary care services. Third, financial limitations or conflicts which reduce capacity and render transfer of care between healthcare sectors difficult. The group recommended the development of ADHD specialism within primary care, along with the transfer of routine and straightforward treatment monitoring to primary care services. Longer term, ADHD care pathways should be brought into line with those for other common mental health disorders, including treatment initiation by appropriately qualified clinicians in primary care, and referral to secondary mental health or tertiary services for more complex cases. Long-term plans in the NHS for more joined up and flexible provision, using a primary care network approach, could invest in developing shared ADHD specialist resources.

CONCLUSIONS

The relegation of adult ADHD diagnosis, treatment and monitoring to specialist tertiary and secondary services is at odds with its high prevalence and chronic course. To enable the cost-effective and at-scale access to ADHD treatment that is needed, general adult mental health and primary care must be empowered to play a key role in the delivery of quality services for adults with ADHD.

Mind the gap: Improving discharge communication between secondary and primary care

Foundation year doctors (FYDs) write most hospital discharge communication, although they have minimal training in this skill. Poor quality discharge summaries increase the risk of adverse events and rehospitalisation. With a multidisciplinary team approach, we developed a list of “golden rules” for good discharge communication. Against these standards, we analysed the quality of electronic inpatient discharge documentation (eIDD) sent over two months from OUH Trust. We found one third of eIDDs were missing details of the discharging doctor. In 68%, changes to medications were not documented clearly and follow-up was not completed in 40%.

To improve this suboptimal state, we implemented interactive teaching sessions for FYDs, designed an e-learning module, and suggested software changes to the current electronic discharge proforma. Early re-audit one month after the first teaching sessions did not demonstrate any significant improvement. However, re-auditing after twelve months is planned.

Through data collection and discussion with key stakeholders, we have identified standards for discharge communication. We developed interventions to help the trust achieve these standards, aiming to enhance patient safety in the peri-discharge period. While discharge communication is delegated to less-experienced team members, they should receive clear guidance and training.

Long-term effects of lithium on renal, thyroid, and parathyroid function: a retrospective analysis of laboratory data

BACKGROUND

Lithium is a widely used and highly effective treatment for mood disorders, but causes poorly characterised adverse effects in kidney and endocrine systems. We aimed to analyse laboratory information system data to determine the incidence of renal, thyroid, and parathyroid dysfunction associated with lithium use.

METHODS

In a retrospective analysis of laboratory data from Oxford University Hospitals National Health Service Trust (Oxfordshire, UK), we investigated the incidence of renal, thyroid, and parathyroid dysfunction in patients (aged ≥18 years) who had at least two creatinine, thyrotropin, calcium, glycated haemoglobin, or lithium measurements between Oct 1, 1982, and March 31, 2014, compared with controls who had not had lithium measurements taken. We used survival analysis and Cox regression to estimate the hazard ratio (HR) for each event with lithium use, age, sex, and diabetes as covariates.

FINDINGS

Adjusting for age, sex, and diabetes, presence of lithium in serum was associated with an increased risk of stage three chronic kidney disease (HR 1·93, 95% CI 1·76-2·12; p<0·0001), hypothyroidism (2·31, 2·05-2·60; p<0·0001), and raised total serum calcium concentration (1·43, 1·21-1·69; p<0·0001), but not with hyperthyroidism (1·22, 0·96-1·55; p=0·1010) or raised adjusted calcium concentration (1·08, 0·88-1·34; p=0·4602). Women were at greater risk of development of renal and thyroid disorders than were men, with younger women at higher risk than older women. The adverse effects occurred early in treatment (HR <1 for length of treatment with lithium). Higher than median lithium concentrations were associated with increased risk of all adverse outcomes.

INTERPRETATION

Lithium treatment is associated with a decline in renal function, hypothyroidism, and hypercalcaemia. Women younger than 60 years and people with lithium concentrations higher than median are at greatest risk. Because lithium remains a treatment of choice for bipolar disorder, patients need baseline measures of renal, thyroid, and parathyroid function and regular long-term monitoring.

FUNDING

None.

Survey of medical students' use of social media

BACKGROUND

Medical students are not sufficiently knowledgeable about the dangers of online social media, and education about how to use it responsibly may be beneficial.

METHODS

We conducted an online questionnaire to assess whether or not medical students in years 2-6 of study at the University of Oxford would intuitively know what doctors should and should not do on social media. We also assessed whether the study intervention of sending out guidance about appropriate use of social media published by the UK General Medical Council (GMC) would improve students' knowledge of how to use social media correctly.

RESULTS

We found that, although social media use was widespread among medical students, the majority were unaware of GMC guidance on this issue. Administration of GMC guidance significantly improved the proportion of GMC-correct responses in four of 16 questionnaire items. Medical students are not sufficiently knowledgeable about the dangers of online social media

DISCUSSION

It is possible that educating medical students about the dangers of online social media, and how to use it appropriately, could be worthwhile.

Morality and markets in the NHS

Since its establishment in 1948, the history of the National Health Service (NHS) has been characterized by organisational turbulence and system reform. At the same time, progress in science, medicine and technology throughout the western world have revolutionized the delivery of healthcare. The NHS has become a much loved, if much critiqued, national treasure. It is against this backdrop that the role of this state-funded health service has been brought into moral question. Certainly, the challenges facing healthcare policy-makers are numerous and complex, but in the wake of the Health and Social Care Act (2012), no issue is more divisive than that of market-based reform. Here we explore the turbulent history of the NHS, from its foundation to the birth of the healthcare marketplace. We explore arguments for and against the healthcare market and resolve that, amid an evolving economic and moral framework, the NHS must ensure that its original tenets of equity and autonomy remain at its core. We propose a values-explicit, systems-based approach to renew focus on both the processes and the outcomes of care.

Reversible acute kidney injury requiring haemodialysis five days after starting dronedarone in a stable 71-year-old man at risk of cardiovascular polypharmacy

We present a case of severe acute kidney injury (AKI) occurring shortly after the initiation of dronedarone therapy, which we suspect was the result of an adverse drug reaction. The mechanism of AKI cannot be definitively determined. The most probable mechanism however involves dehydration secondary to diarrhoea, and medications causing hypotension, both precipitating AKI, further exacerbated by reduced excretion of medications reducing tissue perfusion. This case adds to the growing number of reports submitted to pharmacovigilance authorities regarding the association between dronedarone and AKI. It serves as a reminder of the risks of cardiovascular polypharmacy likely to be prevalent in patients considered for dronedarone (which causes diarrhoea as a common side-effect).

Grazing and vigilance by Soay sheep on Lundy island: influence of group size, terrain and the distribution of vegetation

Animals allocate the time spent on different behaviours according to nutritional requirements, the distribution of food and the risk of predation. When the perceived predation risk is high, animals primarily behave in ways to increase their safety such as regularly scanning their surroundings, forming large groups and feeding in habitats with cover or high visibility. This study investigated which factors Soay sheep (Ovis aries) are most sensitive to in allocating time to different behaviours when the risk of predation is negligible. Continuous focal sampling was used to record the behaviour of the free-ranging Soay sheep on Lundy Island and measures of vegetation, group size and terrain were also recorded. Stepwise multiple regression produced a model of grazing with terrain and range of grass coverage as predictors and a model of vigilance with terrain as a predictor. Sheep grazed for longer on the slopes and as the range of grass cover decreased. They were more vigilant on the slopes. The results support the view that the group size effect largely depends on anti-predatory vigilance and suggest that time-budgets are more sensitive to other factors in the absence of predation.