In recent years, GPs have faced rising expectations that they will intervene earlier to prevent lifestyle-related disease.
Practices will be working to new QOF indicators this year that incentivise them to deliver brief interventions in patients with hypertension who are not active enough, while NICE recently advised practices to tackle rising diabetes by screening all those at risk aged over 40 years and over 25 years in some groups.
As of 1 April, GPs also have a new statutory duty in the NHS Constitution to make ‘every contact count’ to tackle lifestyle change. This requires GPs to provide brief lifestyle advice and/or refer patients to an appropriate service to help them understand how they can improve their health and wellbeing. Advice issued alongside the constitution says: ‘Making Every Contact Count is an opportunity to improve patient care, treatment and outcomes and help people live well for longer.’
But a Pulse investigation reveals that there remains patchy support for GPs who decide to undertake this work.
Data obtained under the Freedom of Information Act from 50 PCTs in March reveals that almost a year after the NICE guidance on diabetes prevention was published, almost half - 42% - still do not provide any lifestyle-change programme for patients diagnosed at risk of developing diabetes, as recommended by NICE. The services available for those with established diabetes are better, with 80% providing a local group education programme.
One in five of the PCTs that responded did not have the NICE-recommended referral services in place for childhood obesity, hypertension or alcohol dependence. Waiting times for some services were up to six months - a delay that experts warn risks undermining the GP intervention.
The need for support
Professor Mike Kirby, professor of medicine at the University of Hertfordshire and a GP in Radlett, says the idea of GPs intervening earlier is a good one but that practices must have appropriate support in order to make any impact on their patients’ health.
For lifestyle interventions to be effective, patients need full-on support.
Professor Mike Kirby
He says: ‘In terms of making every consultation count, there is no point in asking patients [to make changes] if there’s nowhere to direct them.
‘This is a big issue and a significant problem with the NHS health checks. You need plenty of support. In six months’ time they may well have totally forgotten about it. For lifestyle interventions to be effective, patients need full-on support.’
GPC deputy chair Dr Richard Vautrey says that GPs already try to make ‘every contact count’, but adequate access to services is an important issue.
He says: ‘It is easy to criticise general practice but the reality is that if GPs want to refer patients to local services they either don’t exist or the waiting time is so long as to make them worse than useless.
‘The real focus has to be on ensuring that there is consistent provision of services for GPs to be able to refer to.
‘GPs know what services the patients want and all too often they are either not available or there are very long waiting times. That leads to difficult consultations because GPs have to explain why another service isn’t provided where it should be.’
The evidence for GPs intervening is also less than conclusive. A study published in the BMJ last month found GPs trained in motivational techniques were no better at getting patients to adopt healthier habits than those who were not. The Screening and Intervention Programme for Sensible Drinking (SIPS) study found informing patients of their drinking levels and offering a leaflet was just as effective in GP practices as five or 10 minutes of lifestyle counselling.
General practice has a part to play. However, I don’t see it as our primary role
Dr Andrew Buist
Dr Andrew Buist, deputy chair of the Scottish GPC, says: ‘GPs in all parts of the UK are facing demands to promote healthy lifestyles. General practice has a part to play. However, I don’t see it as our primary role, which is to manage illness.
‘Yes, every contact should count, but the demands on our time are such that to have a list of things to go through at each contact is not possible and can only detract from our primary role.
‘The GP practice should be a place to promote healthy living, but GPs are not the best people to do this. Investment in more therapists attached to practices, with the time and skills to teach patients healthier lifestyles, is what’s required.’
Despite this, ministers are keen to press ahead with tying more practice funding to delivering changes in patient behaviour. The Department of Health’s strategy for cardiovascular disease, published in March, tasked NICE with reviewing all the cardiovascular indicators in the QOF in order to improve mortality rates and ensure patients are ‘optimally managed’ in primary care. The report said patients were ‘not always adequately supported’ to improve their lifestyles and urged NHS England to identify how to ‘incentivise and support primary care consistently to provide good management of people with or at risk of CVD’. That review is currently under way.
Professor Mike Richards, domain director for reducing premature mortality at NHS England, says: ‘NHS England has set out its intention to further develop incentives and levers within the new commissioning system in the coming years.
‘We are currently considering how best to incentivise good practice in primary care health promotion and early diagnosis.’
In response to Pulse’s investigation into GP access to services, he insists that improvements are on the way.
‘CCGs and local authorities are already working very closely together through their health and wellbeing boards to develop integrated, joined-up approaches to encouraging healthy lifestyles among their populations, exploring innovative approaches that minimise duplication and give the very best services to patients while making the best possible use of resources.’
But this rosy view fails to convince Dr Vautrey.
‘Whoever is commissioning still has the same problem, which is that there isn’t enough money. It simply isn’t enough to cover the needs as required in the NHS,’ he says. ‘One of the problems is that [priorities] will vary across the country and I think we will see postcode variation,’ he says.
Pulse revealed last month that one local authority in seven has yet to recruit a public health director, and there are fears councillors will put vital GP public health LESs out to tender under local government procurement rules. Professor Kirby is also concerned about GP commissioners’ ability to back the Make Every Contact Count agenda. He says: ‘I am really worried because I think that GPs just won’t engage with it if they have no support from their CCG.’
By actually putting GPs in charge of the commissioning process I see now that we have far more ownership
Dr Andrew Coward
But other GPs are more optimistic that they will get more support to change lifestyles in the new NHS. Dr Andrew Coward, clinical chair of NHS Birmingham South Central CCG, said practices are ‘a lot more involved’ than before.
He says: ‘By actually putting GPs in charge of the commissioning process I see now that we have far more ownership [of the whole process]. We have policy influence.
‘But also I am still a grassroots GP and still see patients two full days a week in surgery. Over 90% of the population go to a GP surgery every 12 to 18 months, so we have that audience.’