Online GP consultations, Pre-eclampsia and could aspirin treat cancer?

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INSIDE HEALTH – Programme 7.

TX: 19.02.19 2100–2130

PRESENTER: MARK PORTER

PRODUCER: PAMELA RUTHERFORD

Porter

Hello. Coming up in the next half hour: Yet another use for aspirin, I interview the researcher behind a new study that suggests it could treat cancer. And preeclampsia – if you’ve ever had a baby you will have been screened for the condition but how much do you actually know about it?

Clip - Vatish

So, when my wife was pregnant, and she’s married to an obstetrician, she said – What’s this preeclampsia thing. And I sat there and I thought – well, if she doesn’t know, then what hope is there for anybody else.

Porter

Morea about preeclampsia later.

But first, the digitisation of the NHS which will, among other things, transform the way that patients interact with their GP. Being able to Skype your doctor from your phone or computer seems to be the most widely promoted example of the sort of change we can all expect. But do video consultations live up to the hype?

Dr Margaret McCartney is in our Glasgow studio. Margaret, how much research has been done in this area?

McCartney

Well not nearly enough. There certainly has been some research done over the last few years looking at the pros and the cons of video consultation and I think it’s fair to say that there are more questions than answers at the moment.

Porter

What sort of cons are there?

McCartney

Well there’s lots. So, the advantages that seem to be touted are things like more efficient, more accurate, allows doctors to spread their workload more evenly, it might allow patients to keep continuity of care with doctors, less travel time, don’t have to get in quite so often. That’s the kind of things people are saying. There’s a really great study that was published in the journal of Medical and Internet Research in 2018 and they looked at the roll out of three clinics trying to do more video consultations and they found in antenatal care they just couldn’t roll it out at all, it was just too difficult to do, it wasn’t popular with their patients or with their doctors. And they found huge problems, actually, in just rolling out the technology itself and they really found that doctors were having to sort of fix technological difficulties that really hadn’t been properly funded or accounted for.

Porter

So, would it be fair to say, that the research doesn’t back what we’re hearing in the media about this as being this new revolution that’s going to impact on the NHS?

McCartney

The research definitely does not back the idea that this is going to be something huge and new, that’s actually going to work for people. Now it might work for some people, some of the time, we shouldn’t write it off but I think we should be very careful of making big claims that simply can’t be held up with the evidence for it. But I think the problem that we have is that it’s being hyped beyond all reason just now and unless we’re really careful and look at the pros and the cons we’re in danger of doing of far more harm than good.

Porter

Thank you, Margaret.

Well video consultations may be grabbing the headlines but a growing number of GP surgeries are opting for another way to boost their offering – online consultations that enable patients to send in their query or concern on any day at any time and their GP will get back to them typically the same or next day with an answer. Which may be anything from a prescription or booking a test to an appointment for a telephone or face-to-face consultation. Well over a thousand practices already offer online consultations and their ranks are swelling by the day.

Around 20 companies offer different IT packages but eConsult is one that’s widely used. London GP Murray Ellender helped found it.

Ellender

Like all GPs we were really struggling with demand and the need to manage lots and lots of patients coming through the door and we knew that there was some solution in digital and wanted to explore different ways of patients interacting with us. And we looked at various options. So, we looked at things like video, as a way to consult but actually video works for some patients but doesn’t save a lot of time, still need 10 minutes of a doctor, 10 minutes of a patient. So, we came up with a different idea, which is gather the history in the patient’s time, push it through to the practice, through to the GP who knows the patient has the record and then let the GP make the decision about what to do.

Porter

So, what does this allow patients to do now, if their practice is using it, that they couldn’t have done before?

Ellender

So, I guess it allows them to contact their GP any time day or night. And it gives patients access to their own GP when they need it. So, I think because of the increasing demands we now have a system where patients have to battle through on the phone at 8 o’clock in the morning in order to secure a face-to-face appointment. Whereas we know that actually not everything has to be handled with a face-to-face appointment, there’s a lot that comes in to general practice, into the consulting room, that could be handled without you necessarily having to come in. So, if we can gather that information up and push it through to the GP, the GP can then make a decision about what to do.

Actuality – phone ringing

Hello, St Stephen’s Health Centre, can I help you?

Kullar

My name is Balvinder, Practice Manager at St Stephens. The complaints and grumbles we were getting were generally around our telephone system and we employed more receptionists and all that seemed to do was drive up demand.

Porter

So, what sort of grumbles were you getting?

Kullar

That the phone wasn’t answered quickly enough, you know if a receptionist is triaging a patient and trying to get some basic clinical information that takes some time.

Porter

People got fed up with being on hold.

Kullar

Yeah, people want immediate access, they don’t want to be kept holding and listening to music.

Porter

So, you knew you had to do something.

Kullar

We had to try something different to improve patient access.

Bower

My name is Rachel Bower, I’m a GP partner here, have been since 2004. As for many GP surgeries we have not as many GPs as we would like. We face a recruitment and retention crisis. Difficult to recruit salaried GPs in particular, so we’re probably about down by 25% on the amount of GP capacity we would like.

Porter

So, in practice that means it’s difficult to get in to see a doctor and when you do there are long waits?

Bower

Yes, I mean we do make sure that we are able to offer emergency appointments when clinically necessary but we’re still sometimes struggling with on-the-day demand.

Porter

St Stephens Health Centre in Tower Hamlets, East London, is a typical busy inner-city practice, it’s been using online consultations since 2013, so how does their current system work?

Ellender

The route in for patients is via the practice website. Most practice websites tend to be picture of the practice and a phone number.

Porter

We’ve got a typical one here on your laptop. So, like many practices, my practice website has a picture of the surgery with a telephone number and other links, all very useful of course.

Ellender

So, what we do with practices is say look make the offer to consult-online really prominent, so here’s the one for St Stephen’s Health Centre. And you can see it’s got the NHS logo, it tells you you’re still on the practice website but actually very prominently it says contact our doctors online.

Porter

So, you’ve got three big orange blocks here, explain what they are.

Ellender

So, here we give patients the option to – they may need help for a specific condition, so I know I’ve got back pain or I think I may have a urinary tract infection. But we’ve got another one for actually I’ve got a series of symptoms, I’m not quite sure what’s wrong. And we’ve also got a section for administrative queries, so I need a letter or I need a repeat of a fit note, that kind of thing.

Porter

Going back to your back pain example, I’ve got back pain and I’ve clicked on this thing here, then what happens, take me through the journey, what we expect to happen to the typical patient?

Ellender

Sure, so the next bit of the journey, the patient will, if they’ve got back pain, we’ll offer them the ability to kind of interact with self-help advice or we can signpost into other services. Or if they think they need a GP we’ll then take a history from them about their back pain.

Porter

And this can be done on a Sunday morning, so they’re at home, they’re not queuing on the phone.

Ellender

Absolutely, they can access this any time. But we’re asking them a history about their back pain, much in the same way that I would ask or you would ask a history if you were sat in front of them. So, it’s a kind of structured history for back pain, within it are red flags for safety – so that actually if there’s a more urgent symptom it’ll pick that up and maybe route them somewhere else. But ultimately, what we’re trying to do is gather a structured history from the patient about their back pain that we then push through to the practice and then when the practice opens they’ll pick that up and present it to the doctor who’ll make a decision about what to do with that patient.

Bower

One of the advantages over the traditional consultation is that they can say up front and it gives them a chance to express themselves in their own time and in the convenience of their own home what it is that they’re after, what their expectation is. Surprisingly, even for mental health problems, this can work quite well. So, they can go into some detail of how they’re feeling and whether they would have a preference for talking therapy or medication, for instance. Another example might be, I’m wondering if I’m anaemic, I’ve got a history of previous anaemia. The advantage of receiving that as an eConsult is that you can streamline it a bit and prioritise it a bit and maybe arrange for them to get a blood test before they come to see you.

Porter

And in terms of your workload here, have you, as a stressed GP, found it helpful, have you noticed a difference?

Bower

It’s difficult to know exactly where to put it in the working day and one wouldn’t want to necessarily over-prioritise these cases simply because it’s a new development and we want it to work. So, the timeline of it is we’re supposed to get back to them by the end of the next working day.

Porter

When do you actually do this, I mean how do you fit it in?

Bower

Well currently, it’s the on-call GP and I would tend to do it in the evening. I might have completed seeing my last emergency patient at that point and maybe done a home visit.

Porter

It sounds to me like you’re – you like the system but you’re actually having to work quite hard at it. Do you think it’s time and resource saving for the practice or is it a quality issue for the service that you’re providing?

Bower

It’s a bit of both of those. I really like the fact that it smooths out the on-the-day demand. You’ve got not people crying for appointments on the day or unhappy – I’ve had to wait weeks and weeks to see you. You’ve established they need to be seen and you’re establishing a slightly better timeframe within which to do that.

Ellender

Patient feedback is overwhelmingly positive. With the kind of conditions they’re consulting for they like the fact that they could spend some time answering questions in their time, they weren’t time pressured and they may then get a prescription issued or some advice issued without them having to take time off work or time out of a busy life looking after kids etc., to come into the surgery. So, actually patients – patients really welcome this.

Porter

And Murray, have you noticed any trends in terms of the sort of conditions that people are enquiring about? Is it different on the system than it would be in face-to-face surgery?

Ellender

One of the things we certainly find is that patients feel a lot more comfortable consulting this way for certain conditions. So, conditions that patients may perceive as embarrassing, things like rectal bleeding or sexual health problems or even mental health, we get a high proportion of patients who come through with anxiety depression because actually they find it a lot easier to express their symptoms and talk about their condition like this, so we’re actually picking up conditions earlier, they’re presenting earlier, than actually making an appointment and overcoming that barrier of going in physically to see a doctor and pick something up. So, actually that’s a really interesting facet of this.

Porter

However, a concern shared by sceptics is that introducing another gateway into the practice simply encourages more contacts and more work. St Stephen’s Practice Manager, Balvinder Kullar.

Kullar

What we’ve seen with the data is that just for December, for example, December 2018 we had 1250 patients contact us via eConsult, out of those 1250 contacts 280 were actually transformed into an eConsult that was delivered to the practice. So, eConsult effectively triaged out approximately a thousand of those contacts by diverting them off to other services. We’re not just recycling these patients, they’re not then coming through another route. So, hopefully it’s stabilising our patient demand.

Ellender

We know from working with lots of practices now you can close about 70% of those consultations down without calling the patient in. So, either with sending them a prescription to the pharmacy and a message to the patient saying go to the pharmacy or you might call them back just to clarify something on the phone but in about 30% you do have to bring in for a face-to-face but you can then triage them according to urgency.

Porter

Who is using it nationally, do you have a profile of the typical user?

Ellender

The biggest age group cohort of users are between the age of 40 and 60. Although we’ve got significant numbers over the age of 65, we’ve even had three users over the age of 100. So, catering to the people who use general practice, don’t assume just because it’s digital it’s the young fit 20-40-year olds because the reality is those people aren’t big users of general practice.

Porter

Murray Ellender. More details, as ever on the Inside Health page of the Radio 4 website. And because online consultation is being adopted so rapidly in primary care, we’ll be keeping a close eye on developments and ongoing research into its impact.

Now, every year in the UK, at least three-quarters of a million pregnant women will be screened at their antenatal appointments for preeclampsia, a potentially lethal complication of pregnancy. Tell-tale clues include high blood pressure, fluid retention and protein in the urine. But how much do women and their partners actually know about the condition?

Dr Manu Vatish from the University of Oxford is part of a team that’s developed a new test, to help manage women at risk. Yet even his family were not as clued up as you might expect.

Vatish

So, when my wife was pregnant, and she’s married to an obstetrician, she said – What’s this preeclampsia thing? And I sat there and I thought – Well, if she doesn’t know, then what hope is there for anybody else?

Porter

What does it actually mean?

Vatish

Well, eclampsia comes from the Greek, meaning lights or sudden flashing of lights and preeclampsia means before that. And I think the historical reference tells you how long this disease has been in our consciousness, that we’re using an ancient Greek word for a disease that still kills a woman every seven minutes on the planet.

Porter

The eclampsia effectively is epileptic type seizures.

Vatish

So, the way the disease works is we know this is a disease caused by the placenta or the afterbirth and we know that sometimes that placenta doesn’t work properly and that happens in the early part of pregnancy and then as you move towards the later part you start to get some symptoms and signs that every pregnant woman goes – why are they dipping my urine, why are they measuring my blood pressure. And we’re looking for high blood pressure, protein in the urine and we’re asking them about certain symptoms and signs that might tell us that eclampsia’s about to happen.

Porter

So, we’re looking for preeclampsia and if we miss it or even if we pick it up sometimes the woman might, rarely in the UK fortunately, progress on to eclampsia.

Vatish

Yes. So, seizures which generally can last several minutes, they represent a fairly impressive threat to the mother’s life and to the baby’s life. And so, we’ve got lots of remedies to try and reduce that fitting but our goal is to try and identify that woman before she ever gets there.

Porter

Because if we don’t pick up preeclampsia, it can lead to seizures and death for the mum. What are the implications for baby?

Vatish

It means the baby’s much smaller than it should be, so it suffers something called intra-uterine growth restriction, which is smaller than it should have been. And the other things that can happen to the baby are it’s often delivered early, is a premature delivery, and the complications of that and occasionally the placenta can actually shear off because the blood pressure’s so high and we call that an abruption and that’s obviously a fairly significant and serious event for the baby.

Porter

And how big a problem is it? I mean every woman is screened for it, how many actually develop some degree of problem with preeclampsia?

Vatish

In the UK it’s around about 3%. But the problem is we don’t know which 3%, so we have to screen 100% to find 3%.

Actuality

Now have you brushed your teeth yet Merlin?

Yes.

Are you going to put a sticker on your top to show that you have? Good boy.

Bagga

My name’s Ushi Bagga, I’ve got two children and I had preeclampsia in both of my pregnancies. It was all a really big shock. Around kind of 32, 33 weeks I started getting quite a lot of swelling in my feet, in my ankles and at the time I just thought that it was probably part of a normal pregnancy symptom – I knew other people that had it and kind of people were just going oh yeah, I remember that. So, I didn’t really think very much of it. And I was going to all my regular antenatal appointments. Every time I went I’d be asked to do a urine test but I really had absolutely no idea what the test was for.

And then it was when I was 35 weeks and I had a midwife appointment on my way to work, so I just sort of popped in. And the midwife took my blood pressure and she was kind of chatting to me and asking how I was. And I happened to mention that I had a headache and also that I thought that I might need to get my eyes checked, so maybe get new contact lenses because my vision wasn’t as clear as it had been. And as soon as I said that, I knew that I’d said something out of the ordinary because the midwife’s face completely changed, she retook my blood pressure. She explained that she wanted me to be admitted to the antenatal ward at St Thomas’ to do some further tests and also to be monitored. And at that point she mentioned preeclampsia.

Vatish

Certainly, being in your first pregnancy is a major risk factor. There’s a genetic input, there’s an immune input. If you change partners and therefore you’ve got a new immune environment, that’s also a risk factor, equivalent essentially to being in your first pregnancy, even though you’ve been pregnant before.

Porter

Because the baby’s genetically different to you, so it presents a challenge to your own immune system.

Vatish

Yes.

Porter

But what’s actually going wrong? I mean when I was training my professor was quite an old chap and he used to refer to toxaemia of pregnancy, as if there was some toxin released into the system.

Vatish

So, in some ways your professor was using quite arcane terminology. But in some ways, he’s actually still quite right. So, the disease is really a disease of your vasculature, your blood vessels, not working properly and the abnormality of those blood vessels results in the high blood pressure and it results in the protein in urine and all the other symptoms and signs that we look for. One of the things that toxaemia defined was poison, I mean I suppose the word itself is toxic and it turns out that actually you’ve got a change in the balance of factors that are released. So, two markers that are known to be released by the placenta are involved in blood vessel growth. One of which is, helping blood vessels to grow, the other one is stopping blood vessels to grow. And what we see in women with preeclampsia there’s more of the molecules that are stopping blood vessels from growing. And Oxford became the first hospital in the UK to be using that as a diagnostic test, it’s a slightly more accurate way than screening people’s blood pressure or urine because your blood pressure can be up for many reasons and you can have protein in your urine for many reasons. And so, the biomarker’s a bit more specific. And the way that test works is that if the test is negative it tells us really strongly that the woman hasn’t got preeclampsia when we see her and also is unlikely to get preeclampsia for the following seven days.

Porter

And that’s important because it affects the management of these women?

Vatish

If we tell somebody that they’ve got preeclampsia or we’re admitting them because we suspect they have preeclampsia there’s anecdotal evidence from around the UK and many colleagues around the world that women are delivered because of the genuine belief that they’ve got preeclampsia. That’s committed the woman to an operative delivery and it’s delivered them of a pre-term baby. It then subsequently becomes apparent that the woman didn’t have preeclampsia and actually had another condition that was very similar. Anything that can help us to improve our diagnostic ability can only be a good thing. And I will say that in Oxford we are currently undertaking a trial to deplete the circulation of these toxins.

Porter

Which involves taking blood from the mother and (in inverted commas) “cleaning” it but what are we taking out then?

Vatish

It’s a protein, the markers that I told you about that we’re using as diagnostics, one of which is vastly elevated in women with preeclampsia, we called it Soluble Flt-1 and the filter we have specifically removes that Soluble Flt-1.

Porter

So, you take their blood, filter it and give it back to them, effectively?

Vatish

Yes. We’ve just done our first patient and extended her pregnancy by several weeks.

Porter

Obviously, the aim of the antenatal care is to spot women who are at risk. What happens when you identify someone who’s got preeclampsia, how do we treat them?

Vatish

Well for the last 2,000 years the treatment has been pretty standard, which is you watch the woman until you’re unable to be sure that she’s still safe and then you deliver her.

Bagga

The consultant said that because of the preeclampsia I’d have to stay in hospital until about 38 weeks when they’d try and induce. I think the thing that I found hardest was that physically I felt absolutely fine, I didn’t feel ill at all but I was being told that I had this life-threatening condition. I was admitted on the Monday and on the Friday my waters broke, quite suddenly in the middle of the night, her heartbeat was showing that she was getting distressed, so, at that point they decided to do an emergency caesarean. She was four weeks early, four pounds 10 ounces, so she was quite small.

Porter

All the best things come in small packages. Ushi Bagga. And there’s a link to the test that Manu Vatish mentioned and more information on preeclampsia on our website.

Aspirin may be over a hundred years old but it’s still full of surprises. And the latest one is that it may have a role in the treatment of cancer. We’ve known for some time that aspirin can reduce the likelihood of developing some forms of cancer but now new research has highlighted a possible role in people who already have the disease.

Professor Peter Elwood from Cardiff University led the study.

Elwood

We put together all the published evidence on aspirin taken by people with cancer. We did a very extensive and careful literature search, we found 71 papers which reported aspirin taking in a wide variety of cancers. We found reduction in cancer mortality and a reduction in the spread of the cancer within the body. The reduction in mortality was around 20%, which means that at any time after diagnosis there will be 20% more people who are taking aspirin alive than people who are not taking aspirin. That’s a pretty astounding result.

Porter

That is remarkable. Do we know how the aspirin might be working?

Elwood

The mechanisms in reducing the spread of cancer within the body have been very well worked out and those mechanisms are dependent, largely, on blood platelets, through a reduction in platelets’ stickiness.

Porter

So, aspirin reduces platelet stickiness, which in turn reduces the likelihood of spread?

Elwood

That’s right. But the effect on the original cancer, itself, are complex, there are effects on the growth of the cancer, on the vascularisation – the development of new blood vessels enabling the cancer to grow – there are these mechanisms but obviously there are probably a whole lot of effects of aspirin on mechanisms to do with cancer growth.

Porter

Aspirin’s long been perceived as a double-edged sword, in that there’s often a price to pay in terms of side effects for any benefit, what were the downsides identified in your review?

Elwood

I was disappointed at the way that the media tended to focus on the risks of aspirin. Now we do not minimise, we do not dismiss the risks of aspirin, but when a patient has been given a diagnosis of cancer the outcome is depressing indeed and the risk of a bleed, which we had already shown is most unlikely to be fatal, is trivial and yet the media, across the world, seem to focus on the risks rather than the benefit.

Porter

Peter, if this was a brand-new drug for cancer that reduced mortality by 20% it would be all over the news.

Elwood

Exactly, it would get headlines and it would be on the BBC daily news, yes.

Porter

What sort of cancers did you look at? Was it just the common forms?

Elwood

We searched the literature and there got all of cancers. The main cancer, of course the most common cancer, is bowel cancer and following that breast cancer and prostate. So, our analysis focused on those three common cancers but our main results are based on all the 71 reports of different cancers, studied by different teams across the world, over the last 30 years.

Porter

Professor Janusz Jankowski is consultant gastroenterologist at Morecombe Bay University Hospital and has a special interest in aspirin and cancer.

Jankowski

This really was a unique study showing potential benefit with very little disadvantage in people with advanced disease. We’ve often referred to aspirin as being almost like a regulator that you’d find on a truck, a speed regulator, so that if the truck was going too fast aspirin generally slows down most of the proliferation of responses in cells, that’s the growth responses, so that the cell doesn’t grow too fast. But what’s unique, if the cell has a mutation it can not necessarily die as frequently as it should. All cells die at some point and what aspirin does is actually it’s a bit like having that truck with the speed regulator and if you can’t regulate the speed of the cells it almost pulls it into the slow lane gravel pit, so that it comes to a stop immediately. So, aspirin’s got very useful effects. Most cells it slows down gently and for some dangerous cells that harbour very rare mutations it can kill very effectively.

Porter

What sort of research do we need to do, Peter, before we can recommend aspirin as a treatment for cancer?

Elwood

Well randomised control trials are the gold standard and it’s really a great relief that there are about six trials being set up. It’ll be five or 10 years before those report and many patients given a diagnosis of cancer will not last to read the results of those trials. But I think the evidence is sufficiently strong to give the patients the choice. They will have a small risk of a bleed, which is most unlikely to be fatal. They’ve got to be given the choice. And an increase of a year or two’s extra survival I think should be balanced by patients against the risks.

Porter

Janusz, getting a definitive answer’s going to take years, what would you say to people with cancer who might want to try aspirin in the meantime?

Jankowski

The most important aspect of this is that there’s an awful lot of patients who are on aspirin already, we think somewhere between 15-25% of the population in this sort of age group of getting cancer might already be on it. So, I think I would want to reassure the patients that they don’t need to come off their aspirin unless there’s a very good reason to do so, if you’re already on it consider it carefully before you come off it and let your doctor make that decision on your behalf. The second point I would make, is that if you consider the risk versus benefit here, the benefits are football size and the risks, particularly if you’re taking acid suppressing drugs, are golf ball size, potentially affecting patients’ perception of whether they should take it or not.

Porter

Professor Janusz Jankowski and there’s a link to Professor’s Elwood’s study on our website.

Next week, we explore hospital related deconditioning. Can a 10 day stay in hospital really age you 10 years? Join me to find out.

ENDS