Family history recording in UK general practice: the lIFeLONG study.

BACKGROUND: In order to integrate genomic medicine into routine patient care and stratify personal risk, it is increasingly important to record family history (FH) information in general/family practice records. This is true for classic genetic disease as well as multifactorial conditions. Research suggests that FH recording is currently inadequate. OBJECTIVES: To provide an up-to-date analysis of the frequency, quality, and accuracy of FH recording in UK general/family practice. METHODS: An exploratory study, based at St Leonard's Practice, Exeter-a suburban UK general/family practice. Selected adult patients registered for over 1 year were contacted by post and asked to complete a written FH questionnaire. The reported information was compared with the patients' electronic medical record (EMR). Each EMR was assessed for its frequency (how often information was recorded), quality (the level of detail included), and accuracy (how closely the information matched the patient report) of FH recording. RESULTS: Two hundred and forty-one patients were approached, 65 (27.0%) responded and 62 (25.7%) were eligible to participate. Forty-three (69.4%) EMRs contained FH information. The most commonly recorded conditions were bowel cancer, breast cancer, diabetes, and heart disease. The mean quality score was 3.64 (out of 5). There was little negative recording. 83.2% of patient-reported FH information was inaccurately recorded or missing from the EMRs. CONCLUSION: FH information in general/family practice records should be better prepared for the genomic era. Whilst some conditions are well recorded, there is a need for more frequent, higher quality recording with greater accuracy, especially for multifactorial conditions.

Taking a family history (FH) of disease can be a quick, cost-effective way of gathering genetic information. Genetic medicine is beginning to transform healthcare, so it is important to gather FH information. General practitioners, also known as family physicians, are in the best position to gather FH information as they regularly see multiple family members. Research suggests that FH recording in general/family practice is not yet good enough. This study aimed to find the areas for improvement by measuring the frequency, quality, and accuracy of FH recording. This study looked at 62 patients' records in one UK general practice. Patients were asked to give up-to-date FH information in a questionnaire which was compared with their record. The study found that some conditions were often recorded. The most commonly recorded condition was heart disease. The conditions that are more likely to reflect the family environment, such as depression, were less frequently recorded. Recordings often included the side of the family the condition affected. Recordings rarely included the age that the relative was affected. The information was not very accurate, as most of the information from patient questionnaires was missing from the records. Research should now focus on how to improve recording.

What factors influence the introduction of a national undergraduate general practice curriculum in the UK?

A national undergraduate curriculum for General Practice might address current concerns regarding intellectual challenge and recruitment through articulating disciplinary knowledge and providing teaching guidance. However, there is ambivalence regarding this idea and the reasons appear incompletely understood. Aims: To better understand ambivalence towards a GP curriculum and to assess the acceptability of a new approach to national curriculum design. Methods: Questionnaire informed by Kotter's model of change, distributed to Heads of Teaching (HOTs) at each UK medical school, regarding the acceptability of both conventional and new approaches to the design of national curriculum guidelines.  Qualitative and quantitative data collection with grounded theory-informed analysis of qualitative data. Results: Support for a conventional, detailed curriculum of clinical conditions is weak but there is strong support for a curriculum outlining general disciplinary principles. Identification with general practice as an independent academic discipline is important in predicting support or otherwise for any type of national curriculum. Conclusion: The identity of GP as an independent academic discipline emerges as a key issue.  Further research on designing and implementing curricula that use principles rather than detailed outcomes is needed.

Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality.

OBJECTIVE: Continuity of care is a long-standing feature of healthcare, especially of general practice. It is associated with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. This review aims to examine whether there is a relationship between the receipt of continuity of doctor care and mortality. DESIGN: Systematic review without meta-analysis. DATA SOURCES: MEDLINE, Embase and the Web of Science, from 1996 to 2017. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Peer-reviewed primary research articles, published in English which reported measured continuity of care received by patients from any kind of doctor, in any setting, in any country, related to measured mortality of those patients. RESULTS: Of the 726 articles identified in searches, 22 fulfilled the eligibility criteria. The studies were all cohort or cross-sectional and most adjusted for multiple potential confounding factors. These studies came from nine countries with very different cultures and health systems. We found such heterogeneity of continuity and mortality measurement methods and time frames that it was not possible to combine the results of studies. However, 18 (81.8%) high-quality studies reported statistically significant reductions in mortality, with increased continuity of care. 16 of these were with all-cause mortality. Three others showed no association and one demonstrated mixed results. These significant protective effects occurred with both generalist and specialist doctors. CONCLUSIONS: This first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates. Although all the evidence is observational, patients across cultural boundaries appear to benefit from continuity of care with both generalist and specialist doctors. Many of these articles called for continuity to be given a higher priority in healthcare planning. Despite substantial, successive, technical advances in medicine, interpersonal factors remain important. PROSPERO REGISTRATION NUMBER: CRD42016042091.

The scientific basis of medical Generalism.

The scientific basis for the various specialties in medicine is strong and is well taught in UK medical schools. This is done by identifying and summarising for medical students the main research which describes and explains the principles of specialist practice. However, ever since 1948, general practice has been the one branch of medical practice which is not taught in this way. Many new doctors qualify believing that general practice is 'hospital medicine outside hospital' and ignorant of important research on general practice as a distinct specialty. This article summarises three research studies showing that psychosocial factors affect the body and influence whether patients live or die. They all occur in the home, family or community and are much more likely to be known to family rather than hospital doctors. Generalist doctors can best see the social determinants of illness, to understand why many diseases occur, and to be able to intervene helpfully. Research clarifies the central role of medical generalists. Both the Royal College of General Practitioners and the Health Select Committee of Parliament have called for this material to be taught in medical schools and the sooner it is the better.

What is the relationship between age and deprivation in influencing emergency hospital admissions? A model using data from a defined, comprehensive, all-age cohort in East Devon, UK.

OBJECTIVES: To clarify the relationship between social deprivation and age as two factors associated with emergency admissions to hospital. DESIGN: Emergency admissions for 12 months were analysed for patients in the NHS NEW Devon CCG. Social deprivation was measured by the Index of Multiple Deprivation (IMD). Logistic regression models estimated the separate and combined effects of social deprivation and age on the risk of emergency admissions for people aged under and over 65. SETTING: East Devon, UK-area of the NEW Devon CCG. POPULATION: 765 861 patients in the CCG database. MAIN OUTCOME MEASURE: Emergency admission to any English hospital. RESULTS: Age (p<0.001) and social deprivation (p<0.001) were significantly associated with emergency admission to hospital, but there was a significant interaction between age and social deprivation (p<0.001). From the third quintile of age upwards, age progressively overtakes deprivation and age has a dominant effect on emergency admissions over the age of 65. The effect of age was J-shaped in all deprivation groups, increasing exponentially after age 40. For patients under 65, age and social deprivation had similar risks for emergency admissions, the differences in risk between the top and bottom quintiles of IMD and age being ∼1.5 and 0.9 percentage points. In patients over 65, age had a much greater effect on the risk of admissions than social deprivation, the differences in risk between the top and bottom quintiles of IMD and age being ∼2.8 and 18.7 percentage points. CONCLUSIONS: Risk curves for all social groups have similar shapes, implying a common biological pattern for ageing in any social group. Over age 65, the biological effects of ageing outweigh the social effects of deprivation. Our model enables CCGs to anticipate and plan for emergency admissions to hospital. These findings provide a new logic for allocating resources to different populations.

Factors influencing consultation length in general/family practice.

BACKGROUND: The length of consultations is an important factor affecting the quality of care in general practice. It is however difficult to study as many factors are simultaneously involved. Much that is known is about patient factors as so far, doctor factors have been neglected. OBJECTIVE: To investigate multiple factors affecting consultation length, how they interact and the association between consultation length and patient-centredness. METHODS: Previously collected observational data from 38 National Health Service NHS GPs in England stratified according to doctor's gender, experience and degree of emotional exhaustion were used. Multiple regression analyses were applied to 822 audio-recorded and timed consultations. Each consultation was analysed for the doctor's gender, patient's gender, experience, level of emotional exhaustion and patient-centredness. RESULTS: We previously reported that 261/564 (46%) of GPs in Essex England were emotionally exhausted. Here, we found that male and female doctors respond differently to both experience and emotional exhaustion, which are associated with differences in their consultation length. The effect of experience on consultation length is only observed in male doctors: the more experienced, the shorter their consultation. Emotional exhaustion affected consultation length in opposite ways for females and male GPs: exhausted female GPs had shorter consultations, while exhausted male doctors had longer ones. Longer consultations were significantly more patient-centred and were associated with female patients. CONCLUSIONS: We found five factors affecting consultation length significantly. Moreover, these factors can predict the consultation length.

Fifty years of longitudinal continuity in general practice: a retrospective observational study.

BACKGROUND: Continuity of care has been defined as relational continuity between patient and doctor and longitudinal continuity describing the duration of the relationship. Measurement of longitudinal continuity alone is associated with outcomes including patient satisfaction, medical costs, hospital admissions and mortality. METHODS: In one UK general practice, records were searched for patients with continuous registration for 50 or more years. Characteristics of these patients were analysed for age, gender, social deprivation, partner registration and length of registration. Trends in numbers and proportions of this group over the previous 14 years were determined. A comparison group of patients, aged 50 or more, and registered in the same practice within the last 2-4 years, was identified. RESULTS: Patients registered for 50 years or more with a median registration of 56.2 years numbered 190 out of a population of 8420 (2.3%). These patients increased in number by 35.3% (1.7-2.3%) over 14 consecutive years. There were no differences between groups for GP consultation rate, number of repeat medications and hospital use, despite the significantly higher prevalence of multi-morbidity, depression and diabetes in patients with high continuity. CONCLUSIONS: This is the first report of 50-year continuity in general practice. Numbers of such patients and proportions are increasing. Longitudinal continuity is easily measured in general practice and associated with important clinical outcomes.