Revealed: Risk of ending up in A&E rises after ‘remote’ GP appointment
Phone patients 14% more likely to go to hospital in next 3 days
PATIENTS given remote GP appointments are more likely to end up going to hospital as emergency cases, a study has found.
Researchers looked at more than 116,000 people in England who had an appointment with a GP, then became so ill within the next three days that they had to be admitted to hospital.
Patients who spoke to a GP over the phone were 14 per cent more likely to take themselves to hospital and end up being admitted than those who had a face-to-face appointment.
The findings suggest doctors are more likely to miss signs of serious illness or patient deterioration when they do not see people.
The authors of the study by Imperial College London say the rise of new appointment types should be ‘carefully investigated’ because of the risk of unintended consequences.
The findings came as the Daily Mail yesterday set out its manifesto campaigning for more faceto-face consultations with GPs.
The study said patients who end up in hospital as emergencies are likely to show signs that their health is deteriorating in the three previous days.
So researchers analysed 116,097 people, between April 2014 and the end of 2017, who had been in contact with their GP and went to hospital three days later.
They took themselves to hospital – rather than being sent by a docple tor – suggesting symptoms had potentially been missed.
Even before Covid struck and remote consultations were rolled out widely, phone consultations made up almost one in five appointments for the people in the study. More than 23,000 out of 116,097 spoke to a GP on the phone.
People given only a telephone appointment were 14 per cent more likely to take themselves to hospital three days later than those seen in-person.
But those seen face-to-face then telephoned by a GP afterwards were 11 per cent less likely to do this, suggesting calls can play an important role in monitoring peoafter they have been seen. Many GPs say telephone consultations are vital to manage demand, are preferred by some patients and work well to quickly deal with straightforward cases.
But the new findings ‘caution against reliance on telephone consultations in primary care’.
However, they say more research is needed to understand what may go wrong in some cases where people have spoken to their doctor over the phone. The study, published in the British Journal of General Practice, found almost one in five GP patients who became emergency hospital patients had already been in hospital or had surgery in the previous 30 days.
Among more than 300million primary care consultations with nonhospital doctors in England each year, only around two per cent ever have an issue which could cause them harm, researchers stressed.
Some seen by a GP may also see their condition deteriorate rapidly afterwards so this could not necessarily have been predicted.
Professor Azeem Majeed, a practising GP and co-author of the study, said: ‘Telephone consultations play an important role in healthcare and, when combined with face-to-face appointments, can help patients manage their health well. But it is essential the
Government’s policy of expanding telephone consultations in March 2020 in response to the pandemic is carefully evaluated.’
He added: ‘It is also essential for the Government to urgently address workforce shortages and capacity issues in NHS.’
Last night, Dennis Reed of Silver Voices, a campaign group for the over-60s, said: ‘We’ve always said that remote consultations are inherently unsafe and this research provides solid backing for the Mail campaign. It is common sense that remote consultations in some cases are going to miss key signs and key symptoms.’
Dr Richard Vautrey, the chairman of the GP committee at the British Medical Association, said: ‘GPs are seeing millions of their patients face-to-face as well as offering telephone and online appointments every week.
‘The move to an initial telephone consultation was, and is, in line with NHS England’s and the Government’s guidance and is still necessary for infection control and to keep patients and healthcare staff as safe as possible. No one wants to leave a surgery with an infection they did not attend with.’
Professor Martin Marshall, chairman of the Royal College of GPs, said: ‘We are still in a pandemic and there is still a need for some infection control measures.’
Over the past six years, Home Office minister rachel Maclean has had such devastating migraines that, at times, she’s had to rush out of parliamentary debates to be sick.
‘I’d often have to do things such as lock myself in a loo cubicle just to get five minutes’ rest before I went back into a debate or a meeting,’ says rachel, 55, Conservative MP for redditch who is married with four children.
The migraines would cause not just nausea and sickness, but also ‘vice-like’ pain in her head during attacks that lasted up to 36 hours and would hit her three or four times a week.
‘Sometimes I had a sensation of drilling inside my skull, especially if I was moving around,’ she says. ‘It was horrible, but there was nothing I could do — I just had to take whatever painkiller I could.’
For days afterwards she would be hit with debilitating exhaustion and brain fog — yet she put off seeking medical help for two years, telling herself that, as she was newly elected as an MP, it was ‘normal to have headaches when I was so stressed and tired’.
Many struggle through as rachel did. A new report from the Migraine Trust charity ‘Dismissed for Too Long’ has found that almost one in four people with migraines wait more than two years from the onset of symptoms to seeking help, even though for many the symptoms will be debilitating enough to stop them living life as normal — and there are now newer treatments that can cut the number of attacks.
As rachel discovered, she now has monthly injections that are having an ‘incredible’ effect.
One of the reasons she delayed seeking help was because she was convinced that she was ‘just’ having headaches, as she believed migraines cause only onesided pain, a common misconception.
‘In actual fact, only two-thirds of migraines are one sided and only 25 per cent have visual disturbances and only 70 per cent have nausea,’ says Peter Goadsby, a professor of neurology at King’s College London.
‘The distinguishing feature of migraine is that it is a headache plus something else — this could be nausea, aura (i.e. visual disturbances, noise and light sensitivity) or brain fog — but you don’t have to have all of them.
‘The other characteristic is that a migraine stops you doing things, whereas with a tension headache you can carry on.’
Around ten million people in the UK are thought to be affected by migraines. The cause is unclear, although attacks are thought to involve temporary abnormal brain activity that affects blood vessels, nerve signals and brain chemicals.
MIGrAIne attacks can be treated with nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, and an anti-sickness drug such as domperidone, only available on prescription.
Stronger drugs called triptans, such as sumatriptan, can be effective too, by stimulating the production of serotonin, a brain chemical thought to reduce inflammation and constrict blood vessels. They don’t prevent migraines but help reduce their severity and duration. However, they don’t work for all.
In 2017, when rachel finally went to the GP, she was given triptans. ‘These took the edge off the pain but took several hours to kick in and left me feeling drugged up and woozy,’ she says. ‘And the day after, it was horrible feeling so drowsy.
‘There were some very dark times. I experienced depression because of the migraines — I felt they were robbing me of my entire life. It wasn’t just my work it affected (although I never missed a vote in the House because of migraines), I’d get the headaches at weekends, on holiday and at Christmas — they didn’t distinguish between work and leisure.
‘It wasn’t as if I could have a few days off and be fine — I couldn’t plan to do anything.’
But now she can, thanks to a newly introduced regular injection. Anti-CGRPs are the first drugs specifically developed to prevent migraines. They work by targeting the CGRP chemical in the brain, which is involved in generating head pain. They block the CGRP and stop it from attaching to its receptors.
Three anti-CGRPs have been approved for use on the NHS in the last 18 months: erenumab, fremanezumab and galcanezumab.
Anti-CGRPs were launched three years ago with much fanfare and hype. Professor Goadsby admits he’d believed the new class of drugs may prove to be less effective outside a research setting (as trials don’t tend to include the worst affected).
‘But I’m surprised at how many people have responded to these drugs who were getting absolutely nowhere with anything else we threw at them,’ he says. ‘Around two-thirds of patients will come back and say the treatment is worth continuing with.’
What’s more, Professor Goadsby says, the side-effects — constipation and injection site issues — are mild. However, anti-CGRPs are only available to those who have failed to control their symptoms with three other treatments and who have at least four migraine days a month.
They must also be prescribed by a headache specialist, such as a neurologist or a GP with a special interest in headaches.
However, few parts of the country have specialist headaches services at all — these are specific headache clinics with a neurologist specialising in migraine or a GP with a special interest in headaches and specialist nurses.
In reply to Freedom of Information requests sent by the Migraine Trust in May this year, only 13 out of the 128 health trusts in england that replied confirmed they ran a service. In Wales, just three out of seven boards had them.
FOr rachel, the anti-CGRP drug has had huge benefits. ‘I was sceptical when I first heard about them, but they have been incredible,’ she says. ‘I’ve only had two or three migraines in the five months I’ve been on the drug — which is a massive improvement.’
However, there is a catch. The drugs cost around £4,800 a year per patient — although the NHS has negotiated confidential discounts with each pharmaceutical company — and patients are still finding them difficult to get on the NHS. rachel managed to access them through the national Migraine Centre charity in London, which runs clinics for the general public.
She went there and a doctor offered to prescribe the injections, after beta blockers (normally used to treat high blood pressure, these are sometimes repurposed to treat migraines because they reduce blood vessel dilation, known to contribute to them) and other painkillers, as well as the triptans, had no effect.
‘I’m not paying anything like £5,000 a year,’ says rachel, although she won’t reveal exactly how much.
‘I understand the position the NHS is in… but obviously in an ideal world the people who desperately need it should be able to access it.’
Some areas of the country are being slow to introduce the new jabs, it seems. ‘Waiting lists for the NHS are very long,’ says Dr Katy Munro, a GP from the national Migraine Centre.
Rachel is speaking about her experience now not just to highlight the treatment options available, but also to highlight ‘the massive amount of stigma surrounding migraine’.
‘One of the worst times was when I had to cancel a meeting with local businessman in my constituency an hour before, as I literally couldn’t get out of bed due to migraine,’ she says.
‘The next time I saw him at a function he said in front of at least 15 people that I hadn’t gone to see him because I’d had a “headache”.
‘We need more sympathy and specific policies to support people with migraine at work. People need to realise that migraine isn’t “just a headache” but can be a completely disabling condition.’