Back to basics: the new patient medical
When patients change their GP practice it is customary to offer some sort of ‘new patient’ check, a task invariably carried out by the practice nurse. But why do we do it, and what information should we expect it to reveal?
New patients arrive in a general practice for a number of different reasons. Some are born, and are automatically enrolled into the baby paraphernalia of paediatric surveillance and vaccinations. These will not usually be thought to need a new patient medical as their needs are served by a different route. Some patients will change GP because of some sort of dissatisfaction. About half such changes are done for reasons of convenience, and about a third because they are expecting a better service elsewhere.1 Other patients will change practice because they have changed address, and this is by far the commonest reason to change.
Despite repeated encouragement from our political masters for patients to adopt a consumerist mentality and vote with their medical cards,2 there is little evidence that any but a minority are doing so. Even the new right (from January this year) to register with a practice not near to the area where you live (and thereby incidentally foregoing the eligibility to a home visit from your GP) has not in my experience attracted many takers. To put this in context, the study cited above (albeit done in 1993) showed that during a 6 month period of around 900,000 patients, about 25,000 changed GP, but only around 3,000 changed GP but did not change address.1 This is consistent with the high satisfaction that patients have with their GP practice – the King’s Fund says 71%,3 but figures from the satisfaction surveys that doctors have to do to achieve reaccreditation (based on patients who have actually recently consulted with a doctor) puts the satisfaction rate at 99%.4
When you come across a new patient in the practice, you will need to be aware of the reasons why people change address. In many cases they have simply moved house. This in itself is a stressful event: a recent survey suggested that moving house was more stressful than bankruptcy, divorce, losing your job, or becoming a parent, factors which ironically may have caused the house move in the first place and also compound the stress caused. Moving house also makes you put on an average of 11 pounds in weight.5 In other cases patients have moved to be nearer to relatives who may also be carers, or have moved to sheltered accommodation or a nursing home in your area: this group are potentially highly vulnerable and already have a number of health issues, take medicines, and are involved with secondary care.
When patients are moving house, registering with a new GP is probably pretty low down on their ‘to do’ list. However, until the registration is achieved then there can be no flow of information to the new practice: the registration is the first step in the process by which medical records are transferred. The electronic transfer of records, where available, has improved this process immeasurably, but where such transfer is not available you are often faced with reams of a computer printout which can seem much more impenetrable than the old Lloyd George paper records, and takes up much more room in the filing cabinets. It is not uncommon that the first interaction with a new patient is an urgent request for repeat medication.
WHY DO A NEW PATIENT MEDICAL?
Doing a ‘medical’, in the sense of seeing newly registered practice patients and subjecting them to checks and investigations, is not a contractual requirement of a general practice. Nevertheless, joining a practice is a good opportunity to review healthcare needs, prescriptions, social support etc, and an opportunity that many practices believe should not be missed. So the ‘New Patient Medical’ is not enforced by the GP contract, or by the QOF, or by the ever more elaborate system of enhanced services: it is done because it is considered good practice. You will remember ‘good practice’ – the things that are done because of your professionalism and taking a pride in the job that you do, concepts hardly encouraged by the target mentality we are all forced to work with.
So some practices routinely offer a medical to new patients, usually an interview with a practice nurse. There will be a protocol to follow or a computer template to complete. Depending on local arrangements this may involve weighing, measuring, taking blood pressure, enquiring after significant health and lifestyle issues, and possibly taking some blood tests. However, a lot of useful information can also be gathered without a face-to-face consultation. Nearly all practices use a questionnaire for newly registered patients. The results of this questionnaire can be used to target patients who need a face-to-face consultation, in particular those who have ongoing health problems. In other practices the questionnaire is the only means of data-gathering, and there is no routine face-to-face medical for any new patient.
The RCGP General Practice Foundation has a view on this, expressed in the General Practice Nurse competencies, and suggests that the new patient check offers an opportunity to address ‘health inequalities, particularly in relation to screening uptake.’6 (Box 1)
The suggested screening programmes which are relevant include: breast cancer; cervical cancer; bowel cancer; prostate cancer; and abdominal aortic aneurysm.7–11It is known that uptake of screening tends to be lower in more deprived sections of the community.12 Practice nurses should help people to access these services where possible. However, it is also important to realise that deprivation is a political problem, and only becomes a health problem by proxy. Also the life values of a middle-class healthcare worker may not accord with all patients.
Where patients have learning difficulties, this may well have been previously identified and so appear in the medical records. As well as additional communication requirements, this may also mean that one or more carers (professional and non-professional) are involved in every discussion.
THE NEW PATIENT QUESTIONNAIRE
The most important medical information that we need in primary care is not secret, and is not the result of examinations, tests or scans. Most of the useful stuff is known to the registering patient, and so giving new patients a questionnaire to fill in is a logical and effective means of information gathering. Based on the questionnaire used in my own practice, these are the bits of information it may be useful to gather:
1. ‘Have you been registered with the practice before?’
If so, there may already be a lot of information on the practice computer, so that any catching up can concentrate just on the period when they were not registered. Many practice nurses are involved in summarising new patient records when they arrive, and a realisation that most of the work is already done comes as a considerable relief. Summarising a couple of medical records is fun, but the novelty soon wears off when faced with dozens of the things. Your practice will probably have a protocol or some guidelines for summarising records and it is as well to be familiar with it.
2. Demographic questions
These include salutation (Mr, Mrs, Ms etc) and a full name. It is all too easy to misplace patients by getting the wrong name, and most computers are not bright enough to realise that you have only got one letter out of place in a patient’s name; it will tell you that the patient does not exist. Having a date of birth helps to distinguish between different patients with the same name, and is some indication of their likely needs: neonates need their vaccinations; fecund ladies need their contraception; older people have had time to accumulate a few illnesses.
Many people appear to want to conduct their entire life over the phone, and accessing healthcare is no exception. Having a reliable phone number is an essential piece of information. Now there are more mobile phones in the world than there are people, texting has become an excellent way of making contact: in my practice we text patients with details of the appointments they have booked, and text them again if they fail to show up.
Our questionnaire also includes a section about ethnicity. It used to be a QOF requirement to gather such data, but this is no longer the case. However, ethnicity can have an effect on healthcare needs (think of the high prevalence of diabetes among people from south Asia). There may be language difficulties, meaning that an interpreter needs to be available for any consultation (a role often filled by a patient’s child who has been born and educated in this country: however consulting via such non-professional interpreters carries its own ethical risks). There may be cultural differences that affect understanding with respect to health. Having a record of ethnicity enables you, should you wish, to conduct audits or even research using this parameter.
3. ‘What is your alcohol consumption?’
Alcohol is no longer mentioned in the QOF Clinical Indicators (it was previously, in relation to a number of clinical conditions), but that does not mean the data is no longer relevant. For the patient with epilepsy, high blood pressure or mental illness, alcohol consumption remains an important risk factor. Our question invites new patients to declare, in units, how much they drink in a week. This does not quite accord with current wisdom that risk is associated not just with total consumption, but also with binge drinking.13 Also people tend to under-report the amount of alcohol they drink,14 making the data not completely reliable. Perhaps a better measure is the one recommended by my ex trainer: ‘An alcoholic is someone who drinks more than their doctor’.
4. ‘How much exercise do you get each week?’
For this year there is no mention of exercise in the QOF, but activity levels have an impact on all manner of illnesses, and on the risks of becoming ill. The latest report on the topic from the Academy of Royal Medical Colleges suggests that exercise can bring about improvements in 13 different health conditions, from heart failure to dementia to depression.15 Exercise is therapeutic and also preventive. However, it is not really clear how much exercise you have to do to get the benefits, most of the recommendations appear to be based on a ‘best guess’ approach. The current official recommendations are so rigorous they would put most people off completely.16 It is not clear how strenuous the exercise has to be: does running around after the kids count? However it remains true that nearly everyone could benefit from increasing the amount of exercise that they do, even by as little as a few minutes a week.17
5. ‘What is your smoking status, and if you smoke would you be interested in stopping?’
Smoking remains the most important modifiable risk factor for ill health, despite it now being a minority habit among adults in the UK. It also has the distinction of being the most mentioned lifestyle factor in the QOF. It is specifically mentioned in the asthma indicators, and also has a section of its own (SMOK002 to 005) where data collection is mandated for 11 different medical conditions. Many of the templates that you will be using for QOF purposes will contain a section where smoking habits can be recorded.
6. ‘What is your height and weight?’
Obesity also has its own QOF section: the requirement is for a practice register of patients over 18 years who have a Body Mass Index of 30 or more. Carrying too much weight puts you at risk of a number of health problems,18 and the heavier you are then the greater the risk. A BMI of 30 or more puts you in the ‘obese’ category. Conversely obesity also adds to the disability conferred by a number of health conditions: if your knees are being required to lug around several unnecessary stones of paunch then they are likely to complain.
7. ‘Have you had any of the following medical problems?’
Our list is: arthritis; cancer; depression; epilepsy; thyroid problem; stroke; heart attack/angina; asthma; COPD; diabetes; hypertension; stomach ulcer and tuberculosis. These are all significant conditions with long-term consequences, and sufferers are likely to turn up in your Long Term Conditions clinics. Nearly all of these diseases also have QOF implications.
8. ‘Are you registered disabled, and if so what is the nature of your disability?’
Disability has an impact on what sort of services a patient is likely to need. Delivering care in the home presents problems of resources not encountered when patients can get to the surgery.
9. ‘Are you a carer?’
The identification of carers is still mentioned in the Mental Health domain of the QOF, and previously featured much more extensively (e.g. dementia). The charity Carers UK estimates that there are 6.5 million carers in Britain, providing unpaid care to a value of £120 billion (slightly more than the entire expenditure on the NHS). Over half are being made ill by their caring duties, with depression being a particular problem.19 Carers are a mainstay of the Primary Healthcare Team, and their contribution and needs require due acknowledgement.
10. ‘Do you consent to share information?’
Many modern GP IT systems allow for the sharing of information between the different professional groups that may be involved in a patient’s care. This makes perfect sense from the point of view of co-ordinating care and ensuring that as much useful information as possible is available to the people who need to know. However, permission is needed from a patient for such sharing – the fact that they have disclosed something to one professional does not automatically mean that they want it shared with every possibly involved professional, whom they may not know. The questionnaire can be used as a way of getting this permission.
11. ‘Do you consent to text messages?’
Many practices now have automatic messaging systems. We use ours to tell patients about their appointments, but the future may bring the ability to send other sorts of information, e.g. test results.
CONCLUSION
When a patient joins the practice, it is an ideal opportunity to tidy things up. It also serves as a ‘welcome’, and a chance to inform new patients about how their new practice works, and what services they can expect. The transfer of records is now, in most cases, quicker and more effective. However, when records are not transferred electronically the summarising task is – if anything – more of a pain in the neck than it used to be.
Most of the information required by the practice does not need a medical to gather. Indeed most practice nurses (and GPs) will confirm that they have plenty of other things to do without engaging in a programme of medicals which is unlikely to yield anything useful. So the New Patient Medical is now usually the New Patient Questionnaire.
It is important from time to time to review the questionnaires being used. Requirements change with time: clinical guidelines change; the QOF changes; the GP Contract changes; technology changes. While writing this article I have been surprised that the practice is still collecting ethnic data, with a potential to cause misunderstanding, but is not collecting information about repeat medication. I will have to have a chat with my Practice Manager.
REFERENCES
1. Billinghurst B & Whitfield M. Why do patients change their general practitioner? A postal questionnaire study of patients in Avon. British Journal of General Practice,1993,43,336-338.
2. NHS Choices. Your choices in the NHS. Choosing a GP. www.nhs.uk/ [Accessed 20.2.15]
3. Mathews-King A. GPs retain top spot for patient satisfaction. Pulse 29 January 2015
4. Revalidation data show patients are satisfied with care they receive from doctors. BMJ Careers 21 January 2015 p2
5. Howarth A. Moving house ‘more traumatic than divorce’. The Scotsman 14 July 2014
6. RCGP General Practice Foundation. General Practice Nurse competencies. December 2012
7. NHS Choices. Breast cancer screening. www.nhs.uk/conditions/breast-cancer-screening [Accessed 25.2.15]
8. NHS Choices. Cervical screening. www.nhs.uk/conditions/cervical-screening-test [Accessed 25.2.15]
9. Public Health England. NHS Bowel Cancer Screening Programme. www.cancerscreening.nhs.uk/bowel [Accessed 25.2.15]
10. Cancer Research UK. PSA (prostate specific antigen) testing for prostate cancer. www.cancerscreening.nhs.uk/prostate [Accessed 25.2.15]
11. NHS Choices. Abdominal aortic aneurysm screening. www.nhs.uk/conditions/abdominal-aortic-aneurysm-screening [Accessed 25.2.15]
12. Public Health England. Levels of socio-economic deprivation affect screening uptake for breast cancer. https://www.gov.uk/government/news/levels-of-socio-economic-deprivation-affect-screening-uptake-for-breast-cancer [Accessed 25.2.15]
13. NHS Choices. The risks of drinking too much. www.nhs.uk/livewell/alcohol [Accessed 21.2.15]
14. Stockwell T et al. Under-reporting of alcohol consumption in household surveys. Addiction 2004 Aug;99(8):1024-33.
15. Academy of Medical Royal Colleges. Exercise: The miracle cure and the role of the doctor in promoting it. February 2015
16. NHS Choices. Physical activity guidelines for adults. www.nhs.uk/livewell/exercise
17. Sparling P. Recommendations for physical activity in older adults. BMJ 2015;350:h100 http://www.bmj.com/cgi/doi/10.1136/bmj.h100
18. NHS Choices. Obesity. www.nhs.uk/Conditions/Obesity [Accessed 21.2.15]
19. Carers UK. www.carersuk.org/ [Accessed 21.2.15]
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