Why current clinical scoring systems don’t work when assessing acutely ill children in general practice

We’re taking a break over Christmas and new year, but we’ll be back at the end of January 2025 with a new BJGP podcast. Look forward to seeing you then!

Today, we’re speaking to Dr Rebecca Payne and Professor Trish Greenhalgh. Rebecca is a GP and an NIHR In Practice Fellow, and works alongside Trish at the Nuffield Department of Primary Health Care Sciences at the University of Oxford. Title of paper: What are the challenges to quality in modern, hybrid general practice? A multi-site longitudinal studyAvailable at: https://doi.org/10.3399/BJGP.2024.0184Quality in primary care is a multidimensional construct embracing effectiveness, efficiency, safety, patient-centredness, equity, continuity, accessibility, and more. We report on how UK practices have striven to deliver on these aspects of quality as they move to a hybrid model that combines in-person with remote and digital care. The context for quality is currently very challenging, with resource constraints, staff shortages, and weak infrastructure. Digital systems intended to increase efficiency have produced some benefits for some people but have created new forms of inefficiency, increased fragmentation of care, contributed to staff stress, and widened inequities of access.

Today, we’re speaking to Dr Dan Butler, a portfolio GP completing his PhD at Queen’s University Belfast. Title of paper: “Challenging but ultimately rewarding”: A qualitative analysis of Deep End GPs’ experiencesAvailable at: https://doi.org/10.3399/BJGP.2024.0167GPs working in the highest need, socioeconomically deprived areas, the “Deep End”, face additional challenges. This paper looks at the NI context and explores why, despite the challenges, GPs choose to work in these areas. The main issues relate to wider healthcare failings and the challenges of patient populations some of whom generally frequently use (‘medicalised’ group) and those who underuse (‘missingness’ group) health services. GPs tend to relate to ‘Deep End’ areas, either due to personal connections or feelings of duty and social responsibility. No amount of General Practice focused funding will ‘solve’ the issues, instead a far greater holistic approach improving the physical conditions people are born, live and work in, is needed.

Today, we’re speaking to Dr Carol Sinnott, a GP and a Senior Clinical Research Associate based at The Healthcare Improvement Studies Institute. Title of paper: Understanding access to general practice through the lens of candidacy: a critical review of the literatureAvailable at: https://doi.org/10.3399/BJGP.2024.0033Dominant conceptualisations of access to health care are often framed in terms of speed and supply — these approaches risk obscuring important aspects of people’s experiences of access. The Candidacy Framework was developed to study access to health care by people in vulnerable groups. This study confirms the salience of the Candidacy Framework for understanding access in the setting of general practice, offering new insights for policy and practice.

Today, we’re speaking to Dr Sarah Sullivan, a Senior Research Fellow based within the Centre for Academic Mental Health at the University of Bristol. Title of paper: External validation of a prognostic model to improve prediction of psychosis in primary careAvailable at: https://doi.org/10.3399/BJGP.2024.0017This paper reports the external validation of the only psychosis risk prediction algorithm to be used in primary care. External validation of prediction algorithms is essential to provide evidence of transportability i.e. that the algorithm can be used outside its training environment. This vital step for prediction algorithms is often missed.

Today, we’re speaking to Dr Sophie Ansems, a GP and PhD candidate, and Dr Lianne Mulder, both based at the Department of Primary and Long-term Care at the University of Groningen in the Netherlands. Title of paper: General practitioners’ perspectives on diagnostic testing in children with persistent non-specific symptomsAvailable at: https://doi.org/10.3399/BJGP.2023.0683It is known that GPs employ diagnostic tests in adults with persistent non-specific symptoms for motives beyond strictly diagnostic purposes, but comparable research has not been conducted in children. This study adds that although GPs want to limit unnecessary invasive procedures in children, non-diagnostic motives to test are considered important, for example to provide reassurance or secure the GP-patient relationship. The decision to conduct diagnostic tests in children with persistent non-specific symptoms is based on a complex trade-off among medical considerations, psychosocial factors, consultation management, and efficient resource utilization. Awareness amongst GPs of the motives underlying their own testing behaviour in children with PNS could prompt changes in their testing practices.

Today, we’re speaking to Dr Amy Clark and Dr Kathryn Hughes. Amy is a resident doctor in North West Anglia Foundation Trust, and Kathryn who is a GP and a Senior Clinical Lecturer based at PRIME Centre Wales within Cardiff University. Title of paper: Assessing acutely ill children in general practice using the National PEWS and LqSOFA clinical scores: a retrospective cohort studyAvailable at: https://doi.org/10.3399/BJGP.2023.0638The validity of the current NICE-recommended scoring system for identifying seriously ill children in general practice, the Traffic Light system, was recently investigated and shown to perform poorly. A new National PEWS (Paediatric Early Warning Score) has just been introduced in hospital settings with hopes for subsequent implementation in general practice, to improve the identification of seriously unwell children. To the authors’ knowledge, the score has not previously been validated in general practice. This study found that the National PEWS would not accurately identify children requiring hospital admission within two days of presenting to general practice with an acute illness and therefore should not be recommended for this purpose without adjustment. Another score, the Liverpool quick Sequential Organ Assessment (Lq-SOFA), was also investigated and found to perform poorly in general practice.

Today, we’re speaking to Professor Carolyn Chew-Graham, Professor of General Practice Research at Keele University. Title of paper: People from ethnic minorities seeking help for Long Covid: a qualitative study.Available at: https://doi.org/10.3399/BJGP.2023.0631People from ethnic minority groups are less likely to present to primary healthcare for Long Covid. This study explored the lived experiences of Long Covid amongst people from ethnic minority groups. Participants were often previously unaware of Long Covid or available support and some described not feeling worthy of receiving care. Experiences of stigma and discrimination contribute to a lack of trust in healthcare professionals and services, and are common in previous negative healthcare encounters. Receiving empathy, validation, and fairness in recognition of symptoms, and support is needed to enhance trust and safety in healthcare.

Today, we’re speaking to Marije Splinter, an epidemiologist and sociologist based at the Department of Epidemiology at Erasmus University Medical Centre in the Netherlands. Title of paper: Healthcare avoidance during the early stages of the COVID-19 pandemic and all-cause mortality: a longitudinal community-based studyAvailable at: https://doi.org/10.3399/BJGP.2023.0637During the COVID-19 pandemic, trends of reduced healthcare-seeking behaviour were observed alongside global patterns of excess mortality, raising concerns about the consequences of healthcare avoidance for population health. This study found that individuals who avoided healthcare during COVID-19 were at an increased risk of all-cause mortality. Importantly, these individuals were characterised by underlying symptoms of depression and anxiety, as well as poor self-appreciated health. The findings of this study emphasise the need for targeted interventions to safeguard access to primary and specialist care for these vulnerable individuals, during and beyond healthcare crises.

Today, we’re speaking to Dr Charlotte Archer, Research fellow in primary care mental health based at the University of Bristol.Title of paper: GPs’ views of prescribing beta- blockers for people with anxiety disorders: a qualitative studyAvailable at: https://doi.org/10.3399/BJGP.2024.0091Beta-blockers are licensed for managing the symptoms of anxiety, and new prescriptions for patients with anxiety have increased substantially in recent years. However, National Institute for Health and Care Excellence guidance for anxiety does not recommend beta-blockers as a treatment for anxiety, and recent reports have highlighted risks associated with the beta-blocker propranolol. Our research found that GPs prescribe beta-blockers for anxiety because they consider them to be low risk, a quicker solution than other treatments, and useful for managing associated physical symptoms.