Epilepsy service provision and re-design with a focus on primary care

This thesis reports four studies which have been designed to promote the greater involvement of primary care in the treatment of epilepsy. The primary aim is to study whether programs of high capacity, low interventional care for people with epilepsy are feasible and effective in primary care, within specific programs. The secondary aims explore the uptake and utility of such programs with preliminary examination on national trends in mortality and hospitalisation for people with epilepsy during the time of the study. 1.) The first study called the Primary Care Clinical Effectiveness program 2 [PRICCE-2] determined the extent to which primary care in East Kent was able to be produce an epilepsy register, ascertain the number of people who were seizure free and identify people at risk from retinal damage from vigabatrin. Also GPs were required to ensure that women were prescribed appropriate contraception and that pregnant women were offered folic acid. The program also studied trends in unplanned visits to hospital which occurred during the program. The PRICCE-2 project demonstrated GPs are willing to participate [89% of eligible practices in 2001] and could identify people who were seizure free [71.25% by the end of the program.] The identification of people on Vigabatrin was also successful identifying 21 people, [20 were expected,] but the ability to support women with epilepsy was less successful. The number of emergency admissions to the local three hospitals for epilepsy was seen to rise steadily, however diagnostic indexing was fairly poor at this stage. 2.) The second study called the Quality and Outcome Framework, determined the extent to which primary care was able to produce an epilepsy register, record seizure frequency, perform a basic epilepsy medication review and 4 determine people who were seizure free. Later on in the study, GPs were required to ensure that women were prescribed appropriate contraceptive medication and offered prenatal advice. The program also studied trends in mortality from epilepsy and trends in unplanned visits to hospital for epilepsy. The study revealed GPs were able to identify people with epilepsy [initially 86.8% rising to 99.8% by 2011], review their medication [95.3% in 2011] and identify people who were seizure free [73.9% in 2011] however they have found it harder to support women with epilepsy with high exception reporting used for this group [36.7% in 2011/12]. The unplanned hospital admissions steadily rose during this time, whilst the mortality for epilepsy began to decline [ R 2 = 0.6118] however whether this was a casual or causal link could not be determined. 3.) The third study determined if primary care could proactively identify social consequences of active epilepsy including the recording of driving status and social factors affected by epilepsy. It also identified and offered women with epilepsy folic acid, pre conception advice and ensured they were prescribed appropriate contraceptive. In addition it required GPs to identify people with epilepsy under hospital care. The study revealed that GPs were able to identify social consequences of epilepsy and identify people under hospital care but once again they found it difficult to support women with epilepsy related issues. The restructuring of PCTs at this time resulted in a loss of data. 4.) The final study determined the extent to which pharmacists can be trained to proactively support people with epilepsy in a Medicines Use Review [MUR] format. Pharmacists grasp of epilepsy before and after training and customer’s knowledge and readiness to approach their pharmacist for support were assessed before and after the consultation. In addition pharmacists were 5 taught how to recognise red flag symptoms and directly refer at risk patients to specialist epilepsy services. The pharmacists readily absorbed the epilepsy training and their customers reported benefit in improved knowledge about epilepsy and also indicated that in future they would seek support for epilepsy from their pharmacist. The direct referral process for epilepsy was not successful however and would need refining in the future. The overall aim to study whether high capacity, low interventional care for epilepsy is both feasible and effective has I believe, been demonstrated in these studies to be possible. Pro-active care for epilepsy is possible in general practice, with GPs being able to provide high capacity epilepsy care. The influence on admission rates and mortality for epilepsy is less clear and requires further study.