UK general practice: Continuing to fail in the care of people with epilepsy?

PURPOSE: To review the standard of clinical care of people with epilepsy (PWE) attending UK general practice after epilepsy was removed from the Quality and Outcomes Framework (QOF) in 2014. METHOD: The case notes of 324 people were reviewed against standards based on National Institute for Health and Care Excellence (NICE), Drug Safety Unit (DSU), and Medicines and Healthcare products Regulatory Agency (MHRA) guidelines. RESULTS: Annual face-to-face review fell significantly (p = 0.021) after the removal of epilepsy from QOF in 2014. Clinical Commissioning Group (CCG) downloaded review rates fell significantly from 95% in 2010 to only 14% in 2016. One hundred and twenty seven (39%) people had seen their GP, and108 (33%) had not seen any doctor, in the past year. One hundred and seventy three (53%) were under specialist care. Forty nine percent not under specialist care had poor control. Two hundred and fifty four (78%) people were on ASM (Anti-Seizure Medication) associated with poor bone health, of these 41 (16%) were prescribed vitamin D. Fourteen women of childbearing age were taking sodium valproate, of whom only 5 (36%) had written confirmation of being counseled of the associated risks. Fifty six (17%) people were non-complaint with prescription collection, of which 66% had documented poor control. There was a discrepancy between actual face-to-face review rates and the review rates the CCG collected. CONCLUSION: This study reveals poor annual review rates for PWE in UK primary care, which have fallen further since the removal of epilepsy from QOF. Unmet needs persist for people with poorly controlled epilepsy not under specialist care, bone health, and the care of women of child bearing age. This study, along with previous work, brings into question the concept of shared care for PWE. Clinical Commissioning Groups should consider investing in the training and employment of GPwSIe (GP with Special Interest in epilepsy) and ENS (Epilepsy Nurse Specialists) to work in the community. The Government should examine re-introducing epilepsy back into QOF with measurable clinical targets and adequate remuneration.

First evidence of the clinical impact of a general practitioner with a special interest in epilepsy.

PURPOSE: The purpose of the study was to review the clinical outcomes of people with epilepsy (PWE) attending a primary care-based specialist epilepsy service. METHOD: The case notes of 355 people attending the service and subsequent follow-up from 2005 to 2013 were reviewed. RESULTS: There had been 37 deaths (all nonattributable to epilepsy), and 38 people had left the area, leaving 280 people who completed the audit. Positive outcomes could be attributed in 94% still attending the service at the end of follow-up. Seventy-five percent of people on treatment, referred with poor seizure control, achieved seizure remission with antiepilepsy drug (AED) changes initiated by the service. CONCLUSION: This study suggests that the majority of people who attended the service had a positive outcome and provides the first evidence for the clinical effectiveness of a general practitioner (GP) with special interest in epilepsy (GPwSIe) and provides support for the recommendations in earlier government reports to promote the use of such a service. Clinical Commissioning Groups (CCGs) and Government should consider investment in this intermediate tier of care as a means to both improving the quality of care and potentially reducing costs.

The role of primary care nurses in the review of stable epilepsy.

AIM: To assess the feasibility of primary care nurses reviewing patients with 'stable' epilepsy. Sample Practice nurses, health visitors, and district nurses drawn from all GP practices in Cheshire West Primary Care Trust. METHOD: Questionnaires were distributed to nursing staff about the management of patients considered to be stable but who require an annual review. RESULTS: Regarding their suitability for the work, there was a significant positive response from practice nurses and district nurses but less so from health visitors, while district nurses and health visitors did not feel they had the spare capacity for the work. CONCLUSION: Inclusion of epilepsy as a quality indicator in the new GP contract means practices are likely to ask primary care nurses to take a role in managing patients with stable epilepsy. From this study there is evidence of some interest in taking this work on but there are issues around capacity, manpower, and funding.

Unmet needs in patients with epilepsy, following audit, educational intervention and the introduction of the New General Practice Contract.

BACKGROUND: Historically, epilepsy care has been documented as poor. The New Contract introduced epilepsy as a quality indicator from April 2004. AIM: To measure the unmet clinical needs in patients with epilepsy, following an audit, with educational intervention and the introduction of the New Contract. DESIGN: Prospective audit. SETTING: Thirteen general practices (population 68 240). METHODS: The case notes of 388 patients receiving treatment for epilepsy were reviewed in the two years before, and four years after, the introduction of the New Contract in April 2004. An intervention took place, which consisted of (a) a letter to each practice summarising the main findings; (b) the provision of a comprehensive template; (c) an individualised categorisation for each patient; (d) a single educational session led by a Neurologist with an interest in epilepsy in March 2004; and (e) the introduction of the New Contract in April 2004. RESULTS: The audit was completed in 267 cases. There was a significant increase in the annual review rate and documentation of seizure frequency. This happened after the New Contract was introduced, and has been sustained. The number of patients under shared care fell significantly from 22% to 16%. Thirty of the 62 (48%) patients with poor control were not receiving shared care. There were 13 referrals and 32 practice interventions related to the audit, with 39 positive outcomes. There was one death in a poorly controlled patient who was not under shared care, nor had been seen regularly by their general practitioner. CONCLUSION: The unmet needs of some patients were highlighted by the audit resulting in appropriate management of these patients. However, despite the significantly improved review rates in primary care, and the availability of specialist services locally, we remain concerned about the proportion of patients with refractory epilepsy who do not seem to be receiving coordinated shared care.