Do virtual renal clinics improve access to kidney care? A preliminary impact evaluation of a virtual clinic in East London

Background

Early identification of people with CKD in primary care, particularly those with risk factors such as diabetes and hypertension, enables proactive management and referral to specialist services for progressive disease.

The 2019 NHS Long Term Plan endorses the development of digitally-enabled services to replace the ‘unsustainable’ growth of the traditional out-patient model of care.Shared views of the complete health data available in the primary care electronic health record (EHR) can bridge the divide between primary and secondary care, and offers a practical solution to widen timely access to specialist advice.

Methods

We describe an innovative community kidney service based in the renal department at Barts Health NHS Trust and four local clinical commissioning groups (CCGs) in east London. An impact evaluation of the changes in service delivery used quantitative data from the virtual CKD clinic and from the primary care electronic health records (EHR) of 166 participating practices. Survey and interview data from health professionals were used to explore changes to working practices.

Results

Prior to the start of the service the general nephrology referral rate was 0.8/1000 GP registered population, this rose to 2.5/1000 registered patients by the second year of the service. The majority (> 80%) did not require a traditional outpatient appointment, but could be managed with written advice for the referring clinician. The wait for specialist advice fell from 64 to 6 days. General practitioners (GPs) had positive views of the service, valuing the rapid response to clinical questions and improved access for patients unable to travel to clinic. They also reported improved confidence in managing CKD, and high levels of patient satisfaction. Nephrologists valued seeing the entire primary care record but reported concerns about the volume of referrals and changes to working practices.

Conclusions

‘Virtual’ specialist services using shared access to the complete primary care EHR are feasible and can expand capacity to deliver timely advice. To use both specialist and generalist expertise efficiently these services require support from community interventions which engage primary care clinicians in a data driven programme of service improvement.

Explaining variation in antidepressant prescribing rates in east London: a cross sectional study

BACKGROUND

Rates of depression and anxiety in south Asian populations are lower than expected. It remains uncertain whether this reflects a real difference in prevalence or differences in case recognition and management.

OBJECTIVE

To examine whether concordance of culture or ethnicity between doctors and patients affects the prescribing rates for antidepressant and anxiolytic medications in general practice populations, taking into account demography, practice size and organization.

METHOD

A cross-sectional general practice study, using practice and demographic data from primary care trusts, doctors' place of qualification from the General Medical Council, combined with practice level prescribing data from the prescription pricing authority (PACT) for the period 2000-2002. Set in 139 practices in the east London primary care trusts (PCTs) of Tower Hamlets, Hackney and Newham, multiethnic areas with large populations of south Asian residents and doctors. The main outcome measure was the annual prescribing rates for each group of drugs, calculated as the mean of two years average daily quantities (ADQs) for each medication, divided by the practice population.

RESULTS

In east London the median prescribing rate (ADQs) for all antidepressants was 7.97 (inter-quartile range 4.91-10.76), for all anxiolytics and hypnotics 2.27 (interquartile range 1.11-3.96). There were significant differences in prescribing rates between practices with UK trained GPs and practices with south Asian trained GPs, with the highest rates of antidepressant prescribing in practices with UK trained GPs and low proportions of south Asian patients. No differences were found in anxiolytic and hypnotic prescribing rates between these practices. 57% of the variation in prescribing between practices could be explained by a model including the place of GP qualification, the proportion of registered women, older (>65) patients, and the list size per full time GP.

CONCLUSIONS

Compared with previous studies prescribing rates for antidepressants have almost doubled over five years, the greatest increase being for selective serotonin re-uptake inhibitors (SSRIs). There is a modest fall in prescribing rates for anxiolytics and hypnotics. Concordance between south Asian practice populations and doctors from similar south Asian cultures is not associated with an increase in antidepressant prescribing. Lower rates of prescribing in practices with south Asian trained doctors occur regardless of the ethnic composition of the practice population. Reasons for these differences are uncertain, but may include differences in explanatory models for presenting symptoms, and management strategies which rely less on a biomedical paradigm.

Relationship style between GPs and community mental health teams affects referral rates

BACKGROUND

Community mental health teams (CMHTs) are the established model for supporting patients with serious mental illness in the community. However, up to 25% of those with psychotic disorders are managed solely by primary care teams. Effective management depends upon locally negotiated referral and shared care arrangements between CMHTs and primary care.

AIM

To examine whether the style of working relationship between general practices and CMHTs affects the numbers and types of referrals from general practices to CMHTs, taking into account population and practice factors and provision of other mental health services which may influence referral rates.

DESIGN OF STUDY

Cross-sectional study.

SETTING

All 161 general practices in East London and the City Health Authority.

METHOD

Questionnaire survey to all general practices to identify style of relationship. Collection of routinely available referral data to all statutory mental health services over a two-year period. Main outcome measures were number and types of referrals from general practices to CMHTs.

RESULTS

The average annual referral rate to the eleven CMHTs in east London is 10 per 1000 adult population annually. The teams show a sixfold variation in rates of referral from all sources. Where good working relationships (a consultation-liaison style) exist between CMHTs and general practice, there are greater numbers of referrals requiring both long and short-term work by CMHTs. Two-stage multivariate models explained 47% of the referral variation between practices. Where primary care-based psychologists work with practices there are greater numbers of CMHT referrals, but less use of psychiatric services.

CONCLUSION

Shifting to a consultation-liaison relationship should increase rates of referral of patients with serious mental illness, including those who can most benefit from the skills of CMHTs. Increasing the provision of primary care-based psychology might improve practice use of mental health services, reducing avoidable outpatient psychiatric referrals.

Characteristics of general practices involved in undergraduate medical teaching

BACKGROUND

The movement of medical education into the community has accelerated the development of a new model of general practice in which core clinical services are complemented by educational and research activities involving the whole primary care team.

AIM

To compare quality indicators, workload characteristics, and health authority income of general practices involved in undergraduate medical education in east London with those of other practices in the area and national figures where available.

DESIGN OF STUDY

A comprehensive survey of undergraduate and postgraduate clinical placements and practice-based research activity within general practice.

SETTING

One-hundred and sixty-one practices based in East London and the City Health Authority (ELCHA).

METHOD

Cross-sectional survey comparing routinely-collected information on practice resources, workload, income, and performance between teaching and non-teaching practices.

RESULTS

In east London, teaching practices are larger partnerships with smaller list sizes, higher staff costs, and better quality premises than non-teaching practices. Teaching practices demonstrate significantly better performance on quality indicators, such as cervical cytology coverage and prescribing indicators. Patient-related health authority income per whole time equivalent (WTE) general practitioner (GP) is significantly lower among teaching practices. A multiple regression analysis was used to explore the association between teaching status and income. Eighty-eight per cent of the variation in patient-related income could be explained by the combination of list size, list turnover, removals at doctor's request, quality of premises, and immunisation and cytology rates.

CONCLUSION

This study demonstrates that practice involvement in undergraduate education in east London is associated with higher scores on a range of organisational and performance quality indicators. The lower patient-related income of teaching practices is associated with smaller list sizes and may only be partially replaced by teaching income. Lower vacancy rates suggest that teaching practices are more attractive to doctors seeking partnerships in east London.

Prescribing rates for psychotropic medication amongst east London general practices: low rates where Asian populations are greatest

OBJECTIVES

The aim of this study was to examine the contribution of Asian ethnicity to the variation in rates of practice prescribing for antidepressant and anxiolytic medication, taking into account other population and practice organizational factors.

METHODS

A practice-based cross-sectional survey was carried out of the prescribing of antidepressants and anxiolytics (daily defined dosages) in 164 general practices. The study was set in East London and the City Health Authority, which includes the multiethnic inner London boroughs of Hackney, Tower Hamlets, Newham and the City of London. The main outcome measures were the annual prescribing rates for each group of drugs, calculated as the total annual daily defined dosages divided by the practice population, and the ratio of antidepressant/ anxiolytic annual prescribing rates.

RESULTS

Prescribing rates for antidepressants showed a 25-fold variation between practices; this was greater for anxiolytics. The median annual prescribing rate for all antidepressants combined was 4.13 (interquartile range 2.50-5.88). For all anxiolytics and hypnotics combined the median annual prescribing rate was 3.55 (interquartile range 1.71-6.36). Univariate analysis showed that Asian ethnicity alone accounted for 28% of the variation in antidepressant prescribing and 20.5% of the variation in the anxiolytic prescribing. A backwards multiple regression model using 10 explanatory practice and population variables accounted for 47.7% of the variance in antidepressant prescribing and 34% of the variance in the anxiolytic prescribing.

CONCLUSION

In practices where the proportion of Asian patients is high, both antidepressant and anxiolytic prescribing is low. This is important for understanding interpractice prescribing variation and for setting levels of drug budgets. This study confirms that the low rates of non-psychotic disorders presented by Asian populations is not a selective feature of access to secondary care, but is evident in the prescribing behaviour of GPs. Uncertainty remains as to how much this is due to a lower prevalence rate, "culture-bound syndromes" or practical difficulties in diagnosis and management within the general practice setting.

Lessons from the London Initiative Zone Educational Incentives funding: associations between practice characteristics, funding, and courses undertaken

BACKGROUND

Following the Tomlinson report of 1992, London Initiative Zone Educational Incentives (LIZEI) funding was introduced for a three-year period to improve recruitment, retention, and educational opportunities for general practitioners working within inner London.

AIM

To test the hypothesis that general practices that show evidence of good organisation achieved better access to LIZEI funding than less organised practices.

METHOD

Observational practice-based study involving all 164 general practices in EAst London and the City Health Authority during the first two years of the scheme, April 1995 to March 1997.

RESULTS

Univariate analysis showed that higher levels of LIZEI funding were associated with practices where there was evidence of good organisation, including higher targets for cervical cytology screening and immunisation rates for under two-year-olds, better asthma prescribing, and training status. Using ten practice and population explanatory variables, multiple regression models were developed for fundholding and non-fundholding practices. Among non-fundholding practices, the asthma prescribing ratio was the variable with the greatest predictive value, explaining 14.7% of the variation in LIZEI funding between practices. Strong positive associations existed between taking further degrees and diplomas, practice size, training, and non-fundholding status.

CONCLUSION

Larger practices, training practices, and those that demonstrated aspects of good practice organisation gained more LIZEI funding: an example of the 'inverse funding law'. Practices within a multifund, based in the Newham locality, gained LIZEI funding regardless of practice organisation. Networks of practices, and, potentially, primary care groups, have a role in equalising the opportunities for education and development between practices in east London.

Factors influencing the attendance rate at accident and emergency departments in East London: the contributions of practice organization, population characteristics and distance

OBJECTIVES

To examine the contribution of general practice organisation, population characteristics and distance to practice attendance rates at four local accident and emergency departments.

DESIGN

Practice-based study examining variations in accident and emergency department attendance rates in 105 practices, using routine data from the Family Health Services Authority (FHSA), the District Health Authority and the 1991 Census.

SETTING

East London and the City Health Authority, covering practices based in the inner city boroughs of Hackney, Tower Hamlets and Newham, and the City of London.

MAIN OUTCOME MEASURE

Practice-based, age-standardized, adult attendance rates at accident and emergency departments in the year to 31 March 1994.

RESULTS

Annual age-standardized practice accident and emergency department attendance rates ranged from 10.3 to 29.4 per 100 population. The mean practice attendance rate was 17.6 per 100 (95% CI 16.8-18.4). No significant relationship was found between attendance rates and practice characteristics (number and sex of general practitioner (GP) principals, presence of practice manager or nurse, computerization and training status). There were strong positive relationships between attendance rates and households not owner-occupied (R = 0.55, P < 0.001) and pensioners living alone (R = 0.55, P < 0.001). There were negative correlations with Asian ethnicity (R = -0.31, P = 0.002) and residents lacking amenities (R = -0.26, P = 0.007). The distance to the nearest accident and emergency department also correlated negatively with attendance (R = -0.27, P = 0.006). A backwards multiple regression model showed that 48% of the variation in attendance rates could be accounted for by six factors: percentage of households not owner occupied, percentage living in households without a car, percentage living in households lacking amenities, percentage of pensioners living alone, percentage of Asian ethnicity, and percentage living in households with a head born in the New Commonwealth and Pakistan. Optimal subsets regression identified a number of alternative models with similar explanatory value.

CONCLUSIONS

Social deprivation is strongly linked with attendance rates at accident and emergency departments in East London. In contrast, the organizational characteristics of general practices appear to have no bearing on the rates. Both purchasers and providers need to take account of these findings when planning accident and emergency provision.

A pilot Diabetic Support Service based on family practice attenders: comparison with diabetic clinics in east London

A pilot Diabetic Support Service (DSS) based on a computer register was devised for diabetic patients identified within three group practices in an inner city district of London. Of 159 eligible diabetics, 142 were followed over 2 years. Glycosylated haemoglobin (GHb) monitoring and adequacy of clinic reviews were audited. Care achieved by the DSS was compared with conventional Diabetic Clinic (DC) management of a sample of 200 diabetics from the same district. Serial GHb measurements were made on 66.2% of DSS and 44.5% of DC patients: GHb fell significantly only in DSS patients (13.1% to 11.4%). Proportional falls in GHb were comparable in each DSS treatment group (diet alone, oral hypoglycaemic agents, and insulin) and for hospital attenders and non-attenders equally. The planned clinical reviews were achieved in 40.1% of DSS patients entered (29% GP only, 54% of clinic attenders) and in 15% of DC patients (plus 75% fundal and blood pressure examination). The study led to provision of a formal diabetic clinic annual review system, diabetic mini-clinics in two of the three group practices, and the appointment of two Diabetic Liaison Sisters. With administrative simplification the system is to be made available to all diabetics in the District through their GPs during 1986-8.

In vitro inhibition of oocyte and follicular maturation and spawning in starfish (Asterias forbesi) by 2-4-dinitrophenol

The in vitro effects of 2-4-dinitrophenol (DNP) on spawning and follicular and oocyte maturation in starfish ovaries and its various cellular components were investigated. Spawning and oocyte and follicular maturation induced by starfish gonadotropin radial nerve factor (RNF) in isolated ovarian fragments were all inhibited by appropriate doses of DNP. DNP inhibits processes which occur shortly after addition of the gonadotropin; in ovarian fragments insensitivity to DNP inhibition occurred shortly after addition of RNF but prior to initiation of spawning. Spontaneous follicular and oocyte maturation which occurred following release of ovarian follicles into sea water was prevented by DNP. In non-spontaneously maturing follicles released from the ovary, DNP inhibited both follicle and oocyte maturation induced by the secondary stimulator of spawning and maturation, 1-methyladenine (1-MA). DNP also inhibited 1-MA induced meiotic maturation in isolated immature oocytes incubated in the absence of follicle cells. Inhibition of oocyte maturation was not associated with inhibition of 3H-1-MA incorporation by isolated oocytes. Immature oocytes incubated in the presence of DNP underwent maturation following washing and subsequent exposure to 1-MA. Immature oocytes initially exposed to both 1-MA and DNP, however, showed decreased maturation responsiveness following washing and re-exposure to 1-MA. The results suggest that the inhibitory effects of DNP on spawning and oocyte maturation are the result of direct effects on the oocytes and possibly other cells and tissues within the ovary.