Investigating suspected colorectal cancer with faecal immunochemical testing (FIT) in primary care: a review of international guidance

Sarah Bailey, University of Exeter

Colorectal cancer is the third most common cancer worldwide, accounting for around 10% of all new cancers, and is the second most common cause of cancer death (1). As the symptoms of colorectal cancer are often vague and frequently caused by benign conditions, selection for investigation can be difficult. As a result, colorectal cancer is often diagnosed at an advanced stage, leaving few curative options (2). Diagnosing colorectal cancer at an earlier stage results in better treatment options and improved survival (3, 4).

Researchers and clinicians are trying to find ways to diagnose colorectal cancer at an earlier stage; one way to achieve this is to investigate people for possible colorectal cancer when they have low risk symptoms, such as stomach ache. The faecal immunochemical test (FIT) has been developed to triage patient with low risk symptoms of colorectal cancer. Those with a positive FIT go on for further investigation, usually by colonoscopy. A negative FIT means that colorectal cancer is extremely unlikely, and the patient does not need any further investigation, although they are advised to see their GP again if their symptoms persist.

The FIT works by detecting small amounts of haemoglobin in a stool sample. Early stage colorectal cancer can cause bleeding into the gut, and the FIT detects that bleeding. Even if the patient has a positive FIT, it does not mean they definitely have cancer – only around 7% do.

Sarah Bailey and Marije van Melle’s poster presentation for systematic review, now published in Family Practice.

FIT has been rolled out across the UK for testing patients with low risk symptoms of colorectal cancer, but guidance for using the test varies in different countries. In this systematic review, led by Dr Sarah Bailey and Dr Marije van Melle and published in Family Practice (5), we reviewed current worldwide recommendations around the assessment of colorectal cancer symptoms to determine how FIT is used to triage patients with symptoms of possible colorectal cancer in primary care.

We found that worldwide guidance for primary care clinicians on the use of FIT varies greatly, and FIT is only recommended for primary care symptomatic patients in three countries: Australia, Spain, and the UK (excluding Scotland). These recommendations are based on a systematic review of studies that included patients with lower GI symptoms suggestive of colorectal cancer (6). That review reported the sensitivity of FIT as 92.1% – 100% (meaning at least 92% of patient with colorectal cancer are identified as such by the test), and specificity as 76.6% – 85.5% (at least 76% of patients without colorectal cancer are correctly identified). Of the 10 studies included in that systematic review, only one was based in primary care (7), where FIT was still performed at the point of referral, rather than to triage referrals.

The evidence on FIT to date comes from heterogenous populations at different stages of the care pathway, with different thresholds, and different assays used; this heterogeneity adds to the difficulty in making clear recommendations. Future updates to recommendations for investigating possible colorectal cancer may begin to integrate FIT for this low-risk CRC symptoms group as more evidence emerges. There is also a lack of evidence about patient preferences for testing with FIT versus colonoscopy; a gap which must be addressed.

 

 

 

References

  1. International Agency for Research on Cancer. Colorectal cancer-Globocan 2018. The Global Cancer Observatory. 2019
  2. McPhail S, Johnson S, Greenberg D, Peake M, Rous B. Stage at diagnosis and early mortality from cancer in England. Br J Cancer. 2015
  3. Statistics O of N. Cancer survival by stage at diagnosis for England (experimental statistics): Adults diagnosed 2012, 2013 and 2014 and followed up to 2015. Off Natl Stat. 2016
  4. Neal RD, Tharmanathan P, France B, Din NU, Cotton S, Fallon-Ferguson J, et al. Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review. Br J Cancer [Internet]. 2015;112 Suppl:S92-107. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25734382
  5. van Melle M, Yep Manzanob S, Wilson H, Hamilton W, Walter FM, Bailey SER. Faecal immunochemical test to triage patients with abdominal symptoms for suspected colorectal cancer in primary care: review of international use and guidelines. Family Practice. 2020;1-9. Available from: https://pubmed.ncbi.nlm.nih.gov/32377668/
  6. Westwood M, Ramos IC, Lang S, Luyendijk M, Zaim R, Stirk L, et al. Faecal immunochemical tests to triage patients with lower abdominal symptoms for suspected colorectal cancer referrals in primary care: A systematic review and cost-effectiveness analysis. Health Technology Assessment. 2017
  7. Mowat C, Digby J, Strachan JA, Wilson R, Carey FA, Fraser CG, et al. Faecal haemoglobin and faecal calprotectin as indicators of bowel disease in patients presenting to primary care with bowel symptoms. Gut. 2016

Hot air, rubbish and going green: Reflections on chairing a SW Clinical Senate Meeting

by Prof David MG Halpin
Consultant Physician & Honorary Professor of Respiratory Medicine

The Climate Change Act of 2008 introduced an ambitious target of reducing greenhouse gas emissions by 80% by 2050 compared to the 1990 levels. In 2008 the NHS generated around 3% of England’s total carbon dioxide emissions making it the largest public sector contributor to greenhouse gas emissions. It is responsible for a staggering 21.4 million tonnes of CO2 emissions each year, 9.5 billion road miles a year – 5% of all road journeys – and 11,300 tonnes of waste a day, of which 22.7% is plastic. Sir Simon Stevens, the NHS Chief Executive, has said “The climate emergency is a health emergency,” and that “the NHS, as the single biggest organisation across this country is both part of the solution and part of the problem. We are 40% of public sector emissions, and although we have reduced our carbon footprint by around a fifth over the past decade, we’ve got to make major changes if we’re going to help this country become carbon net neutral.”

Late last year I chaired a meeting of the South West Clinical Senate held to develop recommendations on high impact changes that healthcare systems can make as meaningful contributions towards mitigating climate change.

Clinical Senates were established as part of the NHS reorganisation in 2012 to provide a source of strategic, independent advice and leadership on how services should be designed to provide the best overall care and outcomes for patients. I have been a member of the Clinical Senate and on its Council since it was established, and have been vice-chair since 2015.

Sitting on the Council is an interesting and rewarding experience – members come from a wide variety of clinical backgrounds and we have considered topics as disparate as student mental health and suicide, biosimilar monoclonal antibodies, weight loss and smoking cessation criteria to improve surgical outcomes, and NHS workforce challenges. The meetings are run in a similar format to the BBC programme “The Moral Maze”. In the morning we hear evidence from a variety of experts, for example John Campbell contributed to the workforce meeting, discussing his research on the challenges facing primary care. In the afternoon, the evidence is discussed in small groups including the external experts and then the Council Members consider all the points that have been made. Following the meeting, the Senate Management Team magically transform all the flip charts and copious notes into draft recommendations.

Topics as disparate as student mental health and suicide have been considered at Senate Meetings

Being vice-chair brings challenges and rewards. The climate change meeting was a great opportunity to promote awareness of work that is being undertaken across the region and elsewhere to reduce greenhouse gas emissions. As I’ve already mentioned, travel is a large factor in the NHS’s carbon footprint and for this meeting we decided we would link to our speakers from outside the region with teleconferencing. Unfortunately, technology in the NHS is not always up to the task, and making it work caused great angst and required the simultaneous use of multiple mobile phones by our Senate Manager and Project Officer. Not surprisingly, one of our recommendations was that IT systems should upgraded to facilitate virtual meetings !

Addressing climate change made members the Senate think about topics, such as waste management, that perhaps they did not give much consideration to as part of their normal working lives. We heard from the Bristol Trusts who have jointly declared a climate emergency following the examples set by Newcastle and Manchester, from the Royal College of Anaesthetists about reducing anaesthetic gas emissions, which are very potent greenhouse gasses, and I presented on the effect of pressurised metered dose inhalers. Inhaler use accounts for 3.1% of the NHS’s carbon footprint. They cause problems both as a result of the release of their propellants during use, but also because of poor disposal and lack of recycling. Even when “empty”, cannisters still contain significant amounts of propellant and unless they are returned to pharmacies for destruction by incineration, the residual propellant will eventually escape, particularly if the inhalers are simply put in domestic waste and sent to landfill sites. Using propellant free devices, when clinically appropriate, should be considered and prescribing guidance from NICE now encourages this.

Other presenters discussed the health impacts of climate change, how virtual consultations can reduce travel and importantly we considered patients’ views which are collated through the Citizens Assembly – which brings together the chairs of the Healthwatches in the South West. We also heard from the Royal College of General Practitioners representative for Sustainability Climate Change and Green issues who talked about the Green Impact for Health toolkit, which is endorsed by the College and designed to help GP surgeries improve their sustainability and environmental impact. More details are available at https://www.greenimpact.org.uk/giforhealth. As well as topics such as green prescribing, practices are encouraged to take steps such as reducing the use of paper, using energy monitors to establish the energy use of the whole practice, providing feedback to staff on energy use and carbon footprint, having an aspiration to reduce energy consumption year-on-year and having a “green impact” standing agenda item at every practice meeting.

As always, with Council meetings, I learned a lot more about a topic I thought I knew something about. You can read the recommendations we came up with, and see the presentations, on the Senate website (https://www.swsenate.org.uk/senate-council-meeting-reducing-nhs-contribution-to-englands-total-carbon-emmisions/2871/).

 

The NHS have reduced their carbon footprint by around 1/5 over the past 10 years.

Making a meal of it: How I sank my teeth into a Cochrane systematic review

Dr Jo Butterworth, GP and NIHR Doctoral Research Fellow.

 

 

 

 

“How are you 300 ahead of me?!” said my colleague, arriving at her desk to start a new day’s work. “Sorry?” I said, finishing off a mouthful of breakfast bar. I already knew what she meant. We’d been ‘competing’ like this for a few days now, egging each other on to maintain our momentum and get through the work on schedule. “Titles and abstracts! You’ve screened 300 overnight!” My mind went back to yesterday evening, sitting in the kitchen watching the potato wedges turn crispy in the oven whilst I flicked through “just a few more” articles on my mobile screening app. I guess that’s the way with screening isn’t it? At the start it’s like being confronted with a gigantic raw potato but once you’ve peeled the skin, gotten rid of a few knobbly bits, you just keep chipping away…

“… if we’d had all of the ingredients to make a shepherd’s pie then we would’ve made a shepherd’s pie, so next time we’re in the kitchen we might think about peeling a few more potatoes.”

In the case of our review of interventions, the evidence was fairly small fry and study authors had chosen different outcomes resulting in a lack of data which could be combined in our analysis. We reached the nevertheless important conclusion that further research was warranted and we made suggestions as to how research teams might go about this.

I never set out to lead on a Cochrane review; my funders thought it might be more than I could chew. However, when both I and the team from Manchester applied to update an existing review, Cochrane served up a sharing platter and suggested that we start with a clean slate. Now, when you’re posing your question and designing your search strategy, you’re just at the tip of the iceberg, with little real idea about where this might lead in terms of the workload ahead.  Well, I can tell you now that there is nothing bite-sized about a Cochrane review.

Serving up and submitting a Cochrane review is what I imagine being a contestant on a well-known television cooking show might be like. You know you won’t get through to the next round if it doesn’t look, smell and taste just as the judges expect. However, there is plenty of guidance available to authors to ensure that their writing is up to standard.

There is also a lot of suggested text, which must not be left out, even if it does not seem applicable. For example, you’re expected to say something like, “if we’d had all of the ingredients to make a shepherd’s pie then we would’ve made a shepherd’s pie, so next time we’re in the kitchen we might think about peeling a few more potatoes”.

Carrying out a Cochrane review is, all-in-all, a highly valuable learning experience and it is the gold standard approach to a systematic review. I am grateful that I have been through the process and for the more sophisticated research palate that I have undoubtedly acquired along the way.

 

Reference:

Butterworth_JE, Hays_R, McDonagh_STJ, Richards_SH, Bower_P, Campbell_J. Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations. Cochrane Database of Systematic Reviews 2019, Issue 10. Art. No.: CD013124. DOI: 10.1002/14651858.CD013124.pub2 .

Society for Academic Primary Care ASM 2019 Exeter – in tweets

All of us here in the Primary Care Research Group really enjoyed hosting the Annual Scientific Meeting (ASM) of the Society for Academic Primary Care (SAPC) 3-5th July 2019 at the fabulous Forum on the University of Exeter’s Streatham Campus. Three days of excellent quality primary care research, catching up with colleagues and friends, forging new connections and collaborations, fun sporting events, a scrumptious conference dinner and above all, beautiful weather!

We would like to share this link with you so that you might see a Twitter snapshot of this great meeting – see if you can spot your Twitter contributions and photographs!

SAPC ASM 2019 Exeter – in tweets – best tried in desktop rather than mobile.

Many thanks to all who attended and all who helped organise this conference, we are still buzzing and very proud to have hosted you all in Exeter this year and are already looking forward to SAPC ASM in Leeds 2020.

Enjoy!

National trainee research collaboratives – Time for general practice to join the party.

Dr Sam Merriel

A career in general practice provides a myriad of opportunities for young and aspiring GPs. The core work as a generalist of providing holistic, patient-centred care to our patients ‘from the cradle to the grave’ and establishing continuity of care with our patients over a long period of time is truly rewarding. GPs can also lend their unique skill sets to other elements of primary care to improve the health of our patients and our community. Developing and building a GP practice or practices through partnership, commissioning NHS services as part of a CCG, and teaching the next generation of GPs are all possibilities open to early career GPs. Academic general practice, contributing to the improvement of primary care through research, is another vital area that GPs can turn their hand to.

But where to start? And how?

First5 GPs and GP trainees are busy people. As GPs we are trained to be lifelong learners, and there is a steep learning curve to begin with in transferring from hospital to community care. Newly qualified GPs need time to find their feet. Some opportunities exist for formal academic training through academic foundation posts in primary care departments, academic clinical fellowships for trainees, and in-practice fellowships for GPs, but these posts are very competitive and require commitment to an academic career. Opportunities to ‘dip one’s toe in the water’ in primary care research are harder to find.

Trainee research collaboratives

A successful model for trainee-led research, audit and quality improvement that has been used by other medical specialties in recent years is that of trainee research collaboratives. These local, regional and national groups exploit the networks of hospital specialty trainees across multiple sites to conduct research and audit projects. The advantages of this approach are that patients can be recruited and data can be quickly and cheaply collected across a number of centres(1). For doctors involved, they can engage in the process on many levels, from identifying patients or collecting data at their local site right through to developing and proposing new ideas for research, audit or quality improvement projects. They can also develop their teamwork, leadership and communication skills(2). Medics without any research experience have the opportunity to gain an insight into how studies are conducted, and their eyes may just be opened to the world of academia.

Trainee research collaboratives in the UK have rapidly expanded in some disciplines in the last 10-15 years. Surgery and anaesthetics in particular have a number of established regional research collaboratives and networks, including the Severn and Peninsula Audit and Research Collaborative for Surgeons (SPARCS) and the South West Anaesthesia Research Matrix (SWARM) in the south west of England. Between 2012 and 2016, the proportion of general surgery units across the UK which participated in at least one study run by trainee research collaboratives grew from 44% to 99%(3). Numerous randomised controlled trials and national audits have been delivered by these collaboratives, resulting in truly impactful research that is improving patient care(4).

PACT – Primary care Academic Collaborative for Trainees

General practice is ideally placed to take full advantage of the trainee research collaborative model. GP trainees are embedded in GP surgeries in all parts of the UK and cover all sections of the population. Electronic medical records can easily be searched for patients who meet inclusion criteria for research and audit, and the general practice model means changes arising from quality improvement projects can more easily be implemented at a local level. General practice in the UK is moving towards networks and federations of practices, making engagement in a collaborative a great opportunity for GP trainees and First5 GPs to experience working with colleagues across multiple GP surgeries towards a common goal.

The Primary care Academic Collaborative for Trainees (PACT) was launched by its chair, Dr Polly Duncan from the Centre for Academic Primary Care in Bristol, at the recent National GP ACF and early career researcher conference in Manchester. We have established a core committee of GP trainees and First5 GPs from right across the UK, and we will be coming to the 48th SAPC Annual Scientific Meeting in Exeter in July to deliver a workshop to develop the very first collaborative project PACT will undertake. PACT will generate numerous opportunities for GP trainees and First5 GPs to bring forward their ideas, and will seek to support them in delivering these projects to improve care for our patients across the UK.

Dr Sam Merriel GP and Clinical Senior Research Fellow, University of Exeter
Vice chair, PACT – Primary care Academic Collaborative for Trainees
@sammerriel

References

  1. Kasivisvanathan V, Kutikov A, Manning TG, McGrath J, Resnick MJ, Sedelaar JPM, et al. Safeguarding the Future of Urological Research and Delivery of Clinical Excellence by Harnessing the Power of Youth to Spearhead Urological Research. Eur Urol [Internet]. 2018;73(5):645–7. Available from: https://doi.org/10.1016/j.eururo.2017.10.026
  2. Kasivisvanathan V, Ahmed H, Cashman S, Challacombe B, Emberton M, Gao C, et al. The British Urology Researchers in Surgical Training (BURST) Research Collaborative: an alternative research model for carrying out large scale multi-centre urological studies. BJU Int. 2018;121(1):6–11.
  3. Nepogodiev D, Chapman SJ, Kolias AG, Fitzgerald JE, Lee M, Blencowe NS. The effect of trainee research collaboratives in the UK. Lancet Gastroenterol Hepatol. 2017;2(4):247–8.
  4. Jamjoom AAB, Phan PNH, Hutchinson PJ, Kolias AG. Surgical trainee research collaboratives in the UK: An observational study of research activity and publication productivity. BMJ Open. 2016;6:e010374.

 

Overseas GP recruitment to bolster the UK GP workforce – how can we maintain registration standards and patient safety?

In the context of our department’s GP workforce research and in light of reports today that GP numbers are showing a sustained drop, Emily Fletcher introduces the ‘GMAP’ project which aims to support the UK’s ambitions to recruit GPs from overseas.

Key points:

  • Across the UK, the number of GPs relative to the size of the population show a sustained drop. GPs are leaving or decreasing their hours in large numbers. Our own survey of GPs indicated that even in South West England, 37% were likely to quit patient care within five years. Some of our work highlights the many reasons for this.
  • The Nuffield Trust reports today that the fall in GPs per person reflects “insufficient numbers previously being trained and going on to join the NHS; more practitioners leaving for early retirement; and failure to recruit enough from abroad”.
  • On the subject of recruiting from abroad, ‘GMAP’ is a research project commissioned by NHS England and the Royal College of General Practitioners in late 2017 to compare the training and experience of overseas GPs to support the UK’s international recruitment ambitions.

International referencing and mapping of UK GP training curricula (GMAP)

Addressing a knowledge and information gap identified by NHS England, and working in collaboration with the Royal College of General Practitioners (RCGP), the GMAP project aimed to develop and pilot a method for mapping GP training and other relevant healthcare system contextual data from an overseas country to the UK, to inform future consideration of streamlined processes for overseas doctors joining the UK GP register.

Professor John Campbell leads the research team, with expert medical education input from Professor Adrian Freeman, international expertise from Dr Emma Pitchforth, project management and data collection overseen by Emily Fletcher and data collection support by Dr Leon Poltawski and Dr Jeffrey Lambert.

Background Over the last six years, the UK has experienced a worsening GP shortage in relation to recruitment and retention. Amongst a number of responses, the UK government and NHS England have sought to develop opportunities for doctors who are suitably qualified as GPs overseas to be attracted to work in the UK. In this context, for doctors outside of the European Economic Area (EEA), there is a need to ensure that their training and experience is appropriate to support them working in UK primary care.

Between the RCGP and the General Medical Council, the ‘Certificate of Eligibility for GP Registration’ (CEGPR) process examines whether doctors have equivalent experience to UK-trained GPs. However, CEGPR is cumbersome, and NHS England commissioned GMAP to develop a method for determining whether a streamlined process for assessing doctors from certain countries was possible.

Method Developing the method involved a number of stages. Our final approach to comparing training and experience of GPs who have trained outside of the UK involved mapping five specific domains: (i) the healthcare context, (ii) the GP training pathway, (iii) the GP curriculum, (iv) Assessment processes, and (v) ongoing continuing professional development and revalidation.

Pilot We published a paper in the BJGP Open in April which outlines the development of the method and its application to a pilot case study site: Australia. We concluded that implementing this systematic method for mapping GP training between countries may support the UK’s ambitions to recruit more GPs and alleviate current GP workforce pressures.

Application Since developing the method, we have gone on to apply the mapping to more countries (South Africa, Canada, and the United States of America) to further support NHS England’s overseas recruitment programme. We are also currently applying the mapping process to GP training in New Zealand.

Mapping these additional countries will inform further considerations of the CEGPR process by the RCGP and GMC as to whether streamlining can be introduced for GPs/family physicians from these countries wishing to enter UK general practice.

My reflections

Whilst GMAP is very different to other research undertaken by our department, it has been hugely interesting and challenging to undertake, and with the added bonus of being of immediate use to NHS England, the RCGP and the GMC. Sadly (for me) no field trips have been required (!) but in writing up the findings for each country I have been fortunate to speak to contacts in each setting who have been generous in giving their time to help refine our interpretations.

Overseas recruitment is hardly the wholesale answer to the UK GP workforce crisis. However, it is important to draw the various strings of our GP workforce research together, and overseas recruitment is one of the many approaches to alleviating the pressure.

Emily Fletcher

Research Fellow

e.fletcher@exeter.ac.uk, @emilyfletcher1

References

  1. Palmer B. Is the number of GPs falling across the UK? Nuffield Trust; 2019. URL: https://www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling-across-the-uk
  2. Baird B, Charles A, Honeyman M, Maguire D, Das P. Understanding pressures in general practice: King’s Fund; 2016.
  3. Fletcher E, Abel GA, Anderson R, Richards SH, Salisbury C, Dean SG, et al. Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners. BMJ Open 2017;7:e015853. http://dx.doi.org/10.1136/bmjopen-2017-015853
  4. Sansom A, Terry R, Fletcher E, Salisbury C, Long L, Richards SH, et al. Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England. BMJ Open 2018;8:e019849. http://dx.doi.org/10.1136/bmjopen-2017-019849
  5. Spooner S, Fletcher E, Anderson C, Campbell JL. The GP workforce pipeline: increasing the flow and plugging the leaks. British Journal of General Practice 2018;68:245. http://dx.doi.org/10.3399/bjgp18X696125
  6. Campbell JL, Fletcher E, Abel G, Anderson R, Chilvers R, Dean SG, et al. Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study. 2019;7:14. http://dx.doi.org/10.3310/hsdr07140
  7. Fletcher E, Sansom A, Pitchforth E, Curnow G, Freeman A, Hawthorne K, et al. Overseas GP recruitment: comparing international GP training with the UK and ensuring that registration standards and patient safety are maintained. BJGP Open 2019; http://dx.doi.org/10.3399/bjgpopen18X101640
  8. NHS England. International GP Recruitment Programme. NHS England. URL: https://www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/international-gp-recruitment/
  9. Fletcher E. Moving into the GP workforce? In: University of Exeter Collaboration for Primary Care (APEx). Exeter; 2019. https://blogs.exeter.ac.uk/apex/blog/2018/10/17/moving-into-the-gp-workforce/

Don’t throw the baby out with the bathwater – asking the right questions when evaluating computerised CBT for depression in primary care

Over a third of all patient visits with a general practitioner are estimated to involve a mental health component, and 90% of these patients are primarily managed in primary

Picture By Jim Wileman – Medical School portraits.

care [1]. Due to this high demand, National Institute of Health and Care Excellence (NICE) guidelines recommend the provision of computerised CBT as an initial lower intensity treatment for depression in primary care [2]. Computerised CBT is more accessible, scalable and cheaper than face-to-face CBT and has the potential to reduce the burden of depression in primary care significantly.

Systematic reviews have confirmed the effectiveness of computerised CBT [3]. However, a randomised controlled trial published in the British Medical Journal in 2015 reported that supported computerised CBT did not improve depression outcomes compared with usual GP care alone [4]. On the back of this, the authors suggested that the routine promotion and commissioning of computerised CBT be reconsidered. I would caution against this for the following reasons:

  • First, it is unlikely that computerised CBT will reduce depression if patients do not adequately use the platform or actively engage with the cognitive and behavioural techniques offline in their day-to-day lives. The median number of online sessions completed by patients in the study by Gilbody et al. ranged from 1–2, and no data were reported concerning offline engagement. Were the negative findings due to an ineffective intervention or the lack of engagement?
  • Second, a large proportion of participants across all arms of the trial were using antidepressants (81%). It is therefore unsurprising that the trial failed to find a positive effect. The argument for computerised CBT is not that is will be more effective than usual care, but that it offers a viable alternative that takes the pressure off general practice and offers patients another treatment option that is less resource intensive.

The issues in the study by Gilbody et al. are by no means unique and are indeed prevalent across the field of computerised interventions for mental health. However, resolving these issues are fundamental to ensure we don’t prematurely reject interventions with the capacity to transform healthcare. As highlighted by the NHS -term plan, harnessing the power of technology and empowering people to take responsibility for managing their own health is vital to meet the increasing demand on healthcare services. This is well within our grasp, but we need to be asking the right questions!

Dr Jeff LambertPostdoctoral Research Associate in Primary Care, UEMS

References

  1. Ferenchick EK, Ramanuj P, Pincus HA. Depression in primary care : part 1 — screening and diagnosis. Br Med J. 2019;
  2. National Institute for Health and Clinical Excellence. Depression in adults: recognition and management. 2018.
  3. Karyotaki E, Riper H, Twisk J, Hoogendoorn A, Kleiboer A, Mira A, et al. Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data. JAMA Psychiatry. 2017;74(4):351–9.
  4. Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, et al. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ. 2015; 1–13.

Introducing the ERICA trial – a trial of Electronic Risk Assessment Tools to help GPs identify cancer sooner

We know that about 10,000 UK cancer deaths a year would not occur if the UK performed as well as its European counterparts in diagnosing cancer early. Much of the problem lies in General Practice – it’s very difficult to identify the patient who may have a cancer explaining their symptoms. There has been a lot of important work conducted by Prof Willie Hamilton and his colleagues who have identified which symptoms of possible cancer actually matter. These studies have led to the development of Risk Assessment Tools (generally abbreviated to RATs). The RATs tell GPs what the patients’ risk of having a possible cancer is and is reported as a percentage. This figure can be calculated for single symptoms (e.g. the risk of cancer of the lung with coughing blood is 2.4%), as pairs of symptoms (coughing blood accompanied by loss of weight is 9.2%) or as repeated symptoms (a re-attendance with coughing blood is 17%). RATs have been developed for 18 different types of cancer and have been given to all UK GPs practices in either paper, mouse mat, calendar, or web-based forms. RATs are useful but are perhaps not immediately accessible to GPs – a GP needs to be thinking about possible cancer and needs to have to the tools to hand to see what a patient’s risk of cancer is.

Recognising this problem, RATs have subsequently evolved. In partnership with Macmillan, the UK cancer charity, electronic versions for seven major cancers (lung, colorectal, pancreas, oesophago-gastric, bladder, kidney and ovarian) have been developed. These eRATs will be integrated into GPs’ clinical software. Using information in patient’s medical records the eRATs automatically prompt the GP when the risk of one or more of these cancers is above 2%. This is an important improvement on the RATs – GPs will be alerted to the small possibility of cancer when they perhaps were not considering it.

The big question that we need to ask ourselves is do these eRATs work? Will they help us catch cancer sooner? Here, in Exeter, led by Prof Willie Hamilton, our team of experts in cancer diagnostics, general practice, health economics, and many other areas are trying to answer this important question. We will do this via a large trial, a trial we are calling ERICA.

We are looking to recruit 530 practices across England. Half of the practices will be given access to the eRATs and half will not. Practices will be in the trial for about 2 years and out of all the patients diagnosed with cancer during this time we will be looking at the stage of the cancer that they are diagnosed with (early vs. late stage). If the eRATs help GPs we might expect to see an increase in early (vs late) cancer stage diagnosis for patients from practices who used the eRATs compared to the practices who did not use them. The study will also explore other important issues such as how the eRATs impact on patients’ and GPs’ experience of care. We will also look at how the eRATs impact NHS costs and the downstream consequences on NHS services.

This trial represents a significant piece of work – it will be the largest trial of cancer diagnostics in general practice in the UK. This trial has only been made possible via a very generous donation of £2m from the Dennis & Mireille Gillings Foundation. It is also being financially supported by Exeter University and Cancer Research UK.

Oh, and my job? I’m responsible for ensuring that we get the trial done on time and within budget. It’s going to be a fantastic challenge and I’m relishing the prospect of supporting our wonderful team to deliver this vital piece of research. We start recruiting practices in summer 2019. Although we won’t have definitive findings until autumn 2023, please do come back to me to get an update on how we’re doing…

Raff Calitri,  ERICA Trial Manager

  • Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study. Thorax. 2005;60(12):1059-65.
  • Hamilton W, Peters TJ, Bankhead C, Sharp D. Risk of ovarian cancer in women with symptoms in primary care: population based case-control study. BMJ. 2009;339:b2998.
  • Hamilton W. The CAPER studies: five case-control studies aimed at identifying and quantifying the risk of cancer in symptomatic primary care patients. Br J Cancer. 2009;101 Suppl 2:S80-6.
  • Hamilton W, Round A, Sharp D, Peters TJ. Clinical features of colorectal cancer before diagnosis: a population-based case-control study. Br J Cancer. 2005;93(4):399-405.
  • Shephard E, Neal R, Rose P, Walter F, Hamilton WT. Clinical features of kidney cancer in primary care: a case-control study using primary care records. Br J Gen Pract. 2013;63(609):e250-5.
  • Shephard EA, Stapley S, Neal RD, Rose P, Walter FM, Hamilton WT. Clinical features of bladder cancer in primary care. Br J Gen Pract. 2012;62(602):e598-604.
  • Stapley S, Peters TJ, Neal RD, Rose PW, Walter FM, Hamilton W. The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case-control study using electronic records. Br J Cancer. 2013;108(1):25-31.

Moving into the GP workforce?

Moving into the GP workforce?

This post is a year late. Mainly, this is due to the many, louder tasks on my Primary Care research to-do list: delivering our final report on the NIHR ReGROUP GP workforce project, writing and submitting further papers from ReGROUP (see below) completing two rapid-fire projects for RCGP on mapping UK and international GP training, attending conferences of the Society for Academic Primary Care (plug: Exeter hosting next year!) and working up two major NIHR funding bids… A busy year.

Nevertheless, the UK’s GP workforce ‘crisis’ has by no means gone away, and here’s some new research findings for you.

Last summer, we surveyed our local GP registrars at the end of their specialty training, as they were ready to move into the workforce. With the help of Health Education England, we surveyed 81 trainees in the South West Peninsula region. Forty five responded (55.5%): 40% male, 60% female, mean age 35.7 years, majority white British and obtained their primary medical qualification from the UK/Ireland:

  • 82.2% (37) intended to move straight into GP-based patient care.
  • 9% (4) intended to take a career break first but then return to GP-based patient care, and one trainee intended to take a career break but ‘may not’ return.
  • A further 6.7% (3) intended to move on to ‘something else’.

Among the 42 intending to, or who may, move into GP work (initial career breaks aside):

  • The majority (28 [66.7%]) planned to work part-time in the long-term, with just 6 (14%) planning to work full-time, and seven (16.7%) who were undecided.
  • Most (32 [76.2%]) had already secured a GP-based clinical post from August 2017. Thirty of these 32 trainees (93.7%) would be working in the South West, and two outside of the UK (one in Europe, the other outside of Europe).
  • Most (34 [81%]) knew what position they would take up: four working as GP partners (9.5%), 18 as salaried GPs (43%), and 12 as locum GPs (28.6%). Three did not know what their role would be and a further five reported an ‘other’ position, including GP retainer and continuing as a GP trainee/registrar.
  • Portfolio working was a popular aim, with many interested in medical education (25 [60%]), three in research (7%), and eight in non-GP clinical work such as sports medicine (19%).
  • Many (24 [57%]) anticipated being involved in delivering out-of-hours care: nine with regular sessions, 15 with occasional sessions.
  • Morale was reported as high or very high by 16 (43%). Twenty reported morale as neither low nor high (47.6%), and four as low (9.5%).
  • A small number already knew that they were likely or very likely to permanently leave GP: three within two years (7%), and four within five years (9%).

It was a small survey and we conducted it a little last minute. But despite taking a year to write about it, the questions remain important to ask.

So, why did we do this? In part, it was because we saw Health Education England publish a similar small survey on the London trainees last summer, and it was also because we are genuinely interested in this. Current GP trainees are the imminent future of the GP workforce, an agenda that we’ve supported with our Exeter research over the last four years.

GPs do a difficult job; they manage a high (rising) and complex workload due to the ageing population and more patients having multimorbidity. Add this to decreased NHS spend on Primary Care and resources for general practice and continually changing care models – GPs are leaving, or decreasing their working hours, in large numbers. Our own survey of South West GPs indicated that 37% were highly likely to quit patient care within five years, a worryingly high figure that is in line with the most recent national figure of 39% from the GP Worklife Survey, and other similar survey findings reported elsewhere in the UK in recent years.

Efforts are focused on both recruitment and retention, across all stages of the workforce ‘pipeline’. Immediate retention of our existing GPs remains essential, and is something we have worked hard to support with our NIHR ReGROUP project. Recruitment to, and growth of, GP training places is equally critical. The government’s target is to recruit 5,000 extra GPs and train over 15,000 GPs by 2020, as well as recruiting 2,000 overseas doctors over the next three years.

It is generally already known what sorts of specialties medical students and graduates want to pursue in their long-term careers: GP is still the most popular first choice, but this is showing a downward trend in recent years compared with other specialties and the percentage of medical graduates preferring GP remains lower than the proportion required to meet workforce needs. We also know about the choices made by Foundation doctors, through the Careers Destination report published by the Foundation Programme. Again, GP specialty training is top of the list and recent growth of training places and record fill rates reported by Health Education England this year after only Round 1 all shows promising progress against government targets.

But why is it important to know what GP registrars plan to do with their careers once they qualify? Surely, they have already been successfully recruited to GP specialty training and have completed the three years of training, spending huge resources gathering the required skills and experience and delivering front-line patient care in general practice?

It matters because we must be alert to the brand new GPs who do not go on to work in a GP job, or who do so on a much reduced basis. And, alarmingly, some of those that qualify are already thinking of permanently leaving GP in the not-distant future. Training a GP all the way from medical school and through specialty training costs just under half a million pounds. If our GP registrars are not moving into the workforce once they qualify, we lose vital and expensive resource.

Something seems to be happening during training. Trainees are being exposed to the issues faced by our current working GPs and that are outlined very clearly in the Wass report. Our (very small and regional) survey adds in a small way to the picture that a percentage of trainees may be lost to the workforce in some way such that growth of training places and recruitment efforts alone will never keep up. Even in the lovely South West where the sun always shines and the surf’s always up.

More work is needed to continue to improve the attractiveness of general practice and address its challenges; progress is being made in some areas but only time will really tell.

With thanks to all of the South West Peninsula GP registrars who completed our last-minute online survey last summer!

, Research Fellow

References from Primary Care Group

  • Campbell J, Calitri R, Sansom A. Retaining the experienced GP workforce in direct patient care (ReGROUP)- final report. Exeter: University of Exeter Medical School; 2015.
  • Campbell JL, Fletcher E, Abel G, Anderson R, Chilvers R, Dean SG, et al. The changing general practitioner workforce: the development of policies and strategies aimed at retaining experienced GPs in direct patient care (ReGROUP) NIHR HSDR 2019 (full ref to be assigned). In: National Institute for Health Research (HS&DR); 2019 (in press, draft available from authors).
  • Fletcher E, Abel GA, Anderson R, Richards SH, Salisbury C, Dean SG, et al. Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners. BMJ Open 2017;7.
  • Sansom A, Terry R, Fletcher E, Salisbury C, Long L, Richards SH, et al. Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England. BMJ Open 2018;8.
  • Spooner S, Fletcher E, Anderson C, Campbell JL. The GP workforce pipeline: increasing the flow and plugging the leaks. British Journal of General Practice 2018;68:245.

 

 

 

 

 

Placement reflection

The Health Services & Policy Research Group hosted two summer interns from the BMedSci programme again this year. They actively contributed to ongoing work and were valued highly within the team. They have both since reported that:

“My 4-week placement with the Health Services & Policy Research Group has been invaluable, exposing me to research and providing a plethora of opportunities to gain crucial techniques and skills that will carry forward not only throughout my undergraduate studies but also to take into the world beyond BSc Medical Sciences. Through working on a scoping review into healthcare system performance for patients with multimorbidity I learned the key differences between scoping reviews systematic reviews, learnt how to perform complex searches in databases, which had previously intimidated me during my undergraduate studies, and helped to screen at text-level, learning the useful ability to read things quickly but thoroughly! I felt incredibly welcomed amongst the team; rather than feeling like a work experience student making tea, I felt fully part of the group, attending meetings and lectures, and learnt a lot by being thrown in at the deep end. I am delighted I have had this wonderful opportunity, gained a wide range of experience, and met brilliant people, and I’d like to thank everyone who made it so great.”

“Being part of a research team focusing on Patient Reported Outcome Measures (PROMs) is a great opportunity for me as a first year medical sciences student. Learning about the diseases in lectures is one thing, but hearing it from a patient’s perspective as to how it affects them is another. The purpose of the study I was part of was to see how chronobiology played a role in the symptoms of the people suffering from multimorbidity. This was specifically narrowed down to people suffering from a combination of asthma, osteoarthritis or depression. Through this, GPs may have a better understanding on how different people express symptoms over the day or year and possibly advise them on when would be a better time for them to take the medication. Based on the results of the questionnaires and the interviews, there are slight variations of symptoms being experienced over the day and seasons. For example, people with osteoarthritis tend to have more pain towards the evenings and people with asthma tend to have a flare up of symptoms when the pollen count is high during the summer. This has also provided a good insight for patients as some may have not noticed a variation in their symptoms before and from this they might be able to better manage their conditions.

It has been pleasurable working with a research team who have been very welcoming to me since my first day which made my experience here even more beneficial. During my placement, I have learned how to input quantitative data into a statistics program called Stata. I have some understanding as to how bids are placed and the process behind it. My time in this placement has definitely sparked my interest in pursuing a career in this field of research.”

UEMS BMedSci students