Should we expect your GP or family doctor to take on more of the day-2-day management of your MS?
In the UK specialist physicians are called consultants because there was always too few of them to get their hands dirty with the day-to-day management of patients with special medical problems. General practitioners used to refer their patients to a specialist for a ‘consultation’ and then get a long letter back with instruction on how to manage their patient. In other words, GPs used to do all the legwork.
In the last 25 years, this has changed. For most long-term conditions, which have become more complicated in terms of their management, the NHS now expects multidisciplinary teams to manage these patients. This has changed the relationships between specialists and GPs and not necessarily in a positive way for patients. For example, we have to rely on GPs to prescribe and help monitor specialist medicines. Not all GPs feel comfortable doing this. If the medicine is off-label they often refuse to prescribe it. There are two reasons for this, (1) why should they pay for an off-label medicine and (2) why should they take on the risks of off-label prescribing. To overcome this we have to put in place so-called shared-care guidelines, which are designed to protect the GPs. Under a shared-care guideline, we have to start and monitor the new medication for the first few months, before the GP takes over the prescribing. The paperwork involved in prescribing drugs under a shared-care guideline is not trivial and takes many meetings and months to get in place, which is why we rely so heavily on our neuroscience specialist pharmacist. Neurologists don’t have the time or space in their job plans to take this on. Notice my use of management speak to delegate this task to our pharmacist.
Because we now see most of our MSers once or twice a year for MS-related problems some rarely see their GPs and hence fall through the cracks, i.e. they are not being routinely monitored for comorbidities (diabetes, hypertension, hypercholesterolaemia, etc.). This causes problems for MSers because MSologists and MS HCPs are not trained and do not have the time to screen for and manage comorbidities.
To implement the marginal gains philosophy into routine MS practice we are going to have to change the way we work with GPs and other community-based HCPs to make the management of MS and all its problems seem seamless to MSers. At the moment it isn’t. A large number of my patients have problems navigating the complexity of the NHS to get the care they need; this is not only community-based services but the services we provide within a secondary care environment.
The Canadian review below on the potential role of the GP or family physician in managing spasticity is refreshing. I see no reason why GPs can’t be upskilled to take on the day-to-day management of many of the symptomatic problems faced by MSers. Spasticity is just one of the symptoms that can be tackled, why can’t they take on bladder, bowel & sexual dysfunction, anxiety, depression, pain, sleep disorders, social isolation, falls prevention, bone health, immunosuppression, diet, smoking, addiction, etc.
What are your experiences with your GP managing your MS compared to your neurologist or MS nurse specialist? Do you think the communication between your MS service and GP could be improved? Do you agree with applying the marginal gains philosophy to the management of your MS?
Milligan et al. Demystifying spasticity in primary care. Can Fam Physician. 2019 Oct;65(10):697-703.
OBJECTIVE: To raise awareness of spasticity in primary care and clarify how to identify, diagnose, and manage it effectively and efficiently in patients with pre-existing neurologic conditions.
SOURCES OF INFORMATION: PubMed was searched for articles published from 1970 to May 2018 using the terms spasticity, spasticity in physical disability, spasticity in mobility impairment, and spasticity with family medicine or primary care. Other relevant guidelines and resources were reviewed and used.
MAIN MESSAGE: Spasticity is a common secondary complication in conditions such as spinal cord injury, multiple sclerosis, stroke, cerebral palsy, and other neuromuscular physical disabilities and can have a negative effect on health and quality of life. Factors such as inconsistent definition, poorly understood mechanism, and relatively low prevalence make spasticity seem like a daunting condition to manage. Furthermore, its variable presentation and effect on a patient’s quality of life, and its range of treatments with varying levels of evidence, can make treatment challenging in primary care and in other clinical settings. Family physicians play an important role in recognizing and inquiring about spasticity and its changes, triggers, and effects on function. Ruling out reversible causes is important. Many management strategies can be instituted by family physicians.
CONCLUSION: Managing spasticity might be unfamiliar to many practitioners. It is important for physicians to understand spasticity and the potential treatment options available to improve quality of life. The current review provides concise information on the clinical relevance of spasticity in primary care and how to assess and manage it effectively and efficiently in those with chronic neurologic conditions.