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GP and Consultants is there a 'disconnect' affecting ongoing care?

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John
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Joined: 09/03/2008

GP and Consultants is there a 'disconnect' affecting ongoing care?

Although we don't normally get involved with the 'medical' side of HIV. Anecdotally, as part of the community, we are hearing of difficulties emerging when HIV+ patients are being pushed to there GP's as the main provider for there care.

For some, diagnosied under a regime of better understanding of the condition, testing earlier and thus before they become unwell.  GP management of healthcare may not present any problems. If the patient is stable on Anti-retroviral therapy then the dependence on the NHS for continuing care maybe no more than the average 'normal' interaction.  Where someone is relatively health with few to no other medical issues GP care is likely to be straightforward.  Assuming of course the GP in question feels able to manage a HIV+ patient. Many lack the experience, knowledge or both.

Some may have enlightened GP's. Those that have established a realtionship of working in partnership with there HIV+ patients. Understanding the approach and the needs with regular updates from secondary care (consultants) to support that relationship.  The GP will have a personal relationship with there patient. They know them. Something becomming increasingly difficult in a stretched GP environment where having constant engagement with a GP you know becomes a luxury.

The issue that seems to be comming up time and again. Affects those who have been long-term diagnosed with multiple other health issues and how the GP supports them.  Those that have become used to a very personal relationship with the consultant(s) that has treated them for many years. Indeed the GP may not even, until recent NHS changes demanded it, have disclosed there status to there GP.  

Now having the GP at the centre of there health for the first time.  Of course they are ensuring that all the necessary information is flowing from there consultants to the GP.  Details of current diagnsosis and treatments.

Herein lies the issue. When the GP then digests this information, checks against local commissioning protocols, within the envelope of there generalist knowledge. Some patients are finding they are now being refused continuing treatments.  When it comes to a prescribed treatment, where the GP is responsible for the prescription, many are refusing to provide the therapy.  Thus the patient is left 'hanging'.  That a consultant has adopted a treatment approach with there patient, sometimes established over a long period of time, this doesn't matter.

As you may know. The new NHS changes have provided that local GP's will be responsible for commissioning services for all patients within there area, called Clinical Commissioning Groups (CCG).  Some, where they have a high local population of HIV+ people realise they need a HIV plan for primary care.  There is already a plan for secondary care that covers HIV treatment and drugs from clinical settings.  Many of these local HIV plans are still to be defined and adapted.  Some CCG's do not even seem to have a plan for there local community figuring in there future planning.

Herein, lies the problem.  Complex HIV+ patients, with several medical conditions for which they take many different medications. Being told they can have this therapy but not that therapy. Ignores the longevity of the realtionship with Secondary care that has led to the treatment being given in the first place.  That the consultant, the specialist, has worked with the patient to find a treatment that the patient can cope with and manage along side there HIV medications. Is brushed aside if it is outside of the understanding or practice of the more 'generalist' GP.  

Treating people with complex HIV health and health related issues, has, over time.  In some cases been an approach of 'trial and error'.  Practioners using the tools at there disposal to treat conditions, bearing in mind HIV drug interactions, to bring relief.  Sometimes these treatments not being the 'norm' but working for the patient none the less.  Monitored, treatments altered or changed to benefit the patient.  All of this effort, an of course cost, wasted.  

We are often told that patients are the key factor in the decisions that affect them. To believe this is to be misled.  It comes down, like many things in life to cost.  For the cohort of HIV+ people with complex medical conditions having interuptions or even the ceasation of therapies I believe this will lead to increased cost as declining health causes more not less interaction with the health service.  Then there is the wasted cost if a GP refers you to a consultant only to over-ride the advice from that consultant by either suggesting a different therapy or none at all.  Of course GP's that a legally liable for the presciptions they write are trying to save themself the potential cost of litigation if they prescribe something that causes harm to there patient or indeed recouping the cost of treatment from there local CCG if they deviate from the approach they have dictated.

Then of course there is the cost of trust.  Clinics will have many patients refered to a "lost to care". Those patients that once engaged with them but no longer do so.  If patients are unable to continue on established therapies, facing a debate at every GP consultation, this may well increase not decrease those "lost to care" as they no longer trust there medical team.  With the financial cost of putting the situation right when the patients health deterioates so badly they require inpatient treatment.

The 'disconnect' is the relationship between consultants, secondary care, and GP's, primary care.  It should not be the case that a GP can over-rule a consultants view.  For many HIV+ people living long term with the illness and with several other health conditions. Unlike the general population. The GP is not likely to have been the centre of there care. 

What needs to happen is a partnership.  More joined up work with patient, consultant and GP to the benefit of keeping the patient as well as possible.  A proper team approach that appreciates all the relationships that exist and facilitate the patient having a 'named GP' that they can build a personal relationship with.  The GP's need to be supported in there decision making and for issues around responsibilites when prescribing.  A team approach that facilitates the GP and Consultant sharing information on treatments the patient is on so that any potential treatment isn't in conflict.  That when a GP is prescribing on the advice of a consultant that this is delegate prescribing with responsibility staying with the consultant that commences it.

Treating HIV has been very progressive in the UK.  The concern here, is that for some, the new NHS changes, are going to undo much of the hard work of keeping those with multiple health issues and HIV independent and managing there health. Yes NHS England have dealt with HIV and HIV medication. However, NHS England need to do much more with local Clinical Commissioning Groups to deal with the complex issues around HIV care for complex patients.  At present it is failing.

 

John
John's picture
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Joined: 09/03/2008

NHS England< - The body responsible for the NHS.

NHS Choices< - this link allows you to find your local Clinical Commission Group

Healthwatch England< - you may well have a local Healthwatch team. Healthwatch is the "consumer champion" within the NHS.

The British Association for Sexual Health (BASHH)< and HIV & the British HIV Association (BHIVA)< may also have guidelines.

Aidsmap/NAM have resources for health< and GP's & Primary care<.

 

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